MEDICARE: GLENDALY FERNANDEZ, PLLC

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	1223G0001X	General Practice Dentistry	31663	TX

General Provider Information

NPI Number	:	1629420666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENDALY FERNANDEZ, PLLC

Provider Business Mailing Address
First Line	:	2515 E ELLIOTT ST
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-3708
Country	:	US
Telephone Number	:	940-696-9701
Fax Number	:

Provider Business Practice Location Address
First Line	:	2515 E ELLIOTT ST
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-3708
Country	:	US
Telephone Number	:	940-696-9701
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	DR. GLENDALY FERNANDEZ
Credential	:	DDS
Telephone Number	:	940-696-9701

Provider Enumeration Date	:	07/01/2016
Last Update Date	:	07/01/2016

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