Provider Demographics
NPI:1124374962
Name:FERNANDEZ, MANUEL J III (DDS)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:J
Last Name:FERNANDEZ
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MANNY
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:22600 VENTURA BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1414
Mailing Address - Country:US
Mailing Address - Phone:818-225-0046
Mailing Address - Fax:818-225-1318
Practice Address - Street 1:22600 VENTURA BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1414
Practice Address - Country:US
Practice Address - Phone:818-225-0046
Practice Address - Fax:818-225-1318
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA358811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice