Healthcare Provider Details

I. General information

NPI: 1760267199
Provider Name (Legal Business Name): KRYSTAL MIYENIA HERNANDEZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 SW 104TH ST UNIT B
OKLAHOMA CITY OK
73139-2990
US

IV. Provider business mailing address

101 NE 53RD ST APT 3003
OKLAHOMA CITY OK
73105-1884
US

V. Phone/Fax

Practice location:
  • Phone: 405-679-2339
  • Fax:
Mailing address:
  • Phone: 580-817-0773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number4695
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: