Healthcare Provider Details

I. General information

NPI: 1770530230
Provider Name (Legal Business Name): ELISEO HERNANDEZ D.M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA #2 KM 47.8 DOCTOR CENTER HOSPITAL TORRE MEDICAL SUITE # 401
MANATI PR
00674-0257
US

IV. Provider business mailing address

PO BOX 257
MANATI PR
00674-0257
US

V. Phone/Fax

Practice location:
  • Phone: 787-854-5633
  • Fax: 787-854-5633
Mailing address:
  • Phone: 787-854-5633
  • Fax: 787-854-5633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1494
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: