=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861119059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIGUEL ALEJANDRO HERNANDEZ AVALOS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2022
-----------------------------------------------------
Last Update Date | 10/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30423 CANWOOD ST STE 121
-----------------------------------------------------
City | AGOURA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-889-4220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 VIA RICARDO
-----------------------------------------------------
City | NEWBURY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-7001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-236-1611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 107494
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------