Provider Demographics
NPI:1316210859
Name:HERNANDEZ, SERGIO (DDS)
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG 6-6837 NORMANDY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:171 INNER LOOP RD
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-0000
Practice Address - Country:US
Practice Address - Phone:760-380-3173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-REN-3113122300000X
MTDEN-DEN-LIC-2432122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist