Provider Demographics
NPI:1093067969
Name:HERNANDEZ, ENRIQUE (ENRIQUE HERNANDEZ)
Entity Type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:ENRIQUE HERNANDEZ
Other - Prefix:DR
Other - First Name:ENRIQUE
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ENRIQUE HERNANDEZ
Mailing Address - Street 1:2539 N KEDZIE BLVD
Mailing Address - Street 2:2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2539 N KEDZIE BLVD
Practice Address - Street 2:2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-1670
Practice Address - Country:US
Practice Address - Phone:773-235-3292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018385122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist