Provider Demographics
NPI:1043959042
Name:HERNANDEZ, ANDREA TANTENGCO (DMD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:TANTENGCO
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 LOCKEFIELD ST APT G
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2936
Mailing Address - Country:US
Mailing Address - Phone:317-702-2058
Mailing Address - Fax:
Practice Address - Street 1:1121 W MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5211
Practice Address - Country:US
Practice Address - Phone:317-702-2058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INLDR2002641223P0700X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program