Provider Demographics
NPI:1407931843
Name:FERNANDEZ, EDMIDIO JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDMIDIO
Middle Name:
Last Name:FERNANDEZ
Suffix:JR
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 1:3920 ROSEMONT DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904
Mailing Address - Country:US
Mailing Address - Phone:706-323-2775
Mailing Address - Fax:706-596-9103
Practice Address - Street 1:3920 ROSEMONT DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-323-2775
Practice Address - Fax:706-596-9103
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10778122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist