Provider Demographics
NPI:1396848339
Name:HERNANDEZ, RAFAEL A (DMD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:A
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AVE FONT MARTELO
Mailing Address - Street 2:#53
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791
Mailing Address - Country:US
Mailing Address - Phone:787-852-4475
Mailing Address - Fax:787-285-0632
Practice Address - Street 1:AVE FONT MARTELO #53
Practice Address - Street 2:104
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-852-4475
Practice Address - Fax:787-285-0632
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR20091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRDM10293-9OtherSTATE DRUG LICENSE