=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073703765
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEDRO LUIS HERNANDEZ DMD, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2007
-----------------------------------------------------
Last Update Date | 11/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 181 KM 3.4 PLAZA TRUJILLO STE 20
-----------------------------------------------------
City | TRUJILLO ALTO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-760-3676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 365 CALLE BARNARD RPTO UNIVERSITARIO
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926-1836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-760-3676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1353
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------