Healthcare Provider Details

I. General information

NPI: 1396848339
Provider Name (Legal Business Name): RAFAEL A HERNANDEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE FONT MARTELO #53 104
HUMACAO PR
00791
US

IV. Provider business mailing address

AVE FONT MARTELO #53
HUMACAO PR
00791
US

V. Phone/Fax

Practice location:
  • Phone: 787-852-4475
  • Fax: 787-285-0632
Mailing address:
  • Phone: 787-852-4475
  • Fax: 787-285-0632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2009
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: