Provider Demographics
NPI:1093159923
Name:FERNANDEZ, ELLYS R
Entity Type:Individual
Prefix:DR
First Name:ELLYS
Middle Name:R
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ELLYS
Other - Middle Name:R
Other - Last Name:TRONILO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3098 FOREST HILL BLVD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5940
Mailing Address - Country:US
Mailing Address - Phone:718-577-8800
Mailing Address - Fax:718-795-9004
Practice Address - Street 1:3098 FOREST HILL BLVD UNIT 2
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33406-5940
Practice Address - Country:US
Practice Address - Phone:718-577-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.024662122300000X
FLDN223821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist