Healthcare Provider Details

I. General information

NPI: 1114457058
Provider Name (Legal Business Name): CRISTINA HERNANDEZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S MAIDEN LN
JOPLIN MO
64801-3084
US

IV. Provider business mailing address

520 W 34TH ST
JOPLIN MO
64804-3612
US

V. Phone/Fax

Practice location:
  • Phone: 417-782-0080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number2017017904
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: