Healthcare Provider Details

I. General information

NPI: 1124830989
Provider Name (Legal Business Name): DR. CUTBERTO A. HERNANDEZ SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 01/20/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVENIDA LIBERTAD Y CALLE 17 #1608
SAN LUIS RIO COLORADO SONORA
83447
MX

IV. Provider business mailing address

PO BOX 4927
SAN LUIS AZ
85349-4927
US

V. Phone/Fax

Practice location:
  • Phone: 928-514-6545
  • Fax:
Mailing address:
  • Phone: 928-514-6545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3872672
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: