Healthcare Provider Details

I. General information

NPI: 1821038191
Provider Name (Legal Business Name): ANGEL IVAN HERNANDEZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB. BRASILIA ST. MARGINAL M-19 SUITE #3
VEGA BAJA PR
00693
US

IV. Provider business mailing address

PO BOX 3654
VEGA ALTA PR
00692-3654
US

V. Phone/Fax

Practice location:
  • Phone: 787-858-2400
  • Fax: 787-858-2400
Mailing address:
  • Phone: 787-858-2400
  • Fax: 787-858-2400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2029
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: