Healthcare Provider Details

I. General information

NPI: 1972614154
Provider Name (Legal Business Name): ANTHONY R HERNANDEZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5116 AMERICAN FAMILY DR
MADISON WI
53718-8331
US

IV. Provider business mailing address

5116 AMERICAN FAMILY DR
MADISON WI
53718-8331
US

V. Phone/Fax

Practice location:
  • Phone: 608-825-7500
  • Fax: 608-825-0010
Mailing address:
  • Phone: 608-825-7500
  • Fax: 608-825-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0005488
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: