Provider Demographics
NPI:1053866517
Name:E.WENDY HERNANDEZ, DDS, INC
Entity Type:Organization
Organization Name:E.WENDY HERNANDEZ, DDS, INC
Other - Org Name:HEAVENLY KIDS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELSA
Authorized Official - Middle Name:WENDY
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-251-1312
Mailing Address - Street 1:12920 RUNWAY RD UNIT 310
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2313
Mailing Address - Country:US
Mailing Address - Phone:424-785-8708
Mailing Address - Fax:424-785-8718
Practice Address - Street 1:1210 N LONG BEACH BLVD STE 196
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-1685
Practice Address - Country:US
Practice Address - Phone:424-785-8708
Practice Address - Fax:424-785-8718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56388122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1497938401OtherDENTIST
CA1437580644OtherELSA W HERNANDEZ, DDS, INC