MEDICARE: GUSTAVO HERNANDEZ D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6692	NV

General Provider Information

NPI Number	:	1093181810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUSTAVO HERNANDEZ D.M.D.

Provider Business Mailing Address
First Line	:	2074 BRASSY DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-2036
Country	:	US
Telephone Number	:	702-283-6276
Fax Number	:

Provider Business Practice Location Address
First Line	:	9771 S EASTERN AVE STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89183-6801
Country	:	US
Telephone Number	:	702-616-9655
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2015
Last Update Date	:	08/16/2015

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