Provider Demographics
NPI:1164808895
Name:FERNANDEZ, PABLO A (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:PABLO
Middle Name:A
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10190 W PLUM TREE CIR
Mailing Address - Street 2:APT 203
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 W WISCONSIN AVE
Practice Address - Street 2:ROOM 141
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2186
Practice Address - Country:US
Practice Address - Phone:414-288-7388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001187-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist