Healthcare Provider Details

I. General information

NPI: 1912634643
Provider Name (Legal Business Name): EDWARD ANTHONY HERNANDEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 COUNTRY CLUB DR
TOOELE UT
84074-9655
US

IV. Provider business mailing address

613 COUNTRY CLUB DR
TOOELE UT
84074-9655
US

V. Phone/Fax

Practice location:
  • Phone: 208-201-0354
  • Fax:
Mailing address:
  • Phone: 208-201-0354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14286615-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: