Provider Demographics
NPI:1417098260
Name:MARIO HERNADEZ, DDS, INC
Entity Type:Organization
Organization Name:MARIO HERNADEZ, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-585-5891
Mailing Address - Street 1:1870 FOREST HILL BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAKE CLARKE SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33406-8901
Mailing Address - Country:US
Mailing Address - Phone:561-585-5891
Mailing Address - Fax:561-586-6014
Practice Address - Street 1:1870 FOREST HILL BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE CLARKE SHORES
Practice Address - State:FL
Practice Address - Zip Code:33406-8901
Practice Address - Country:US
Practice Address - Phone:561-585-5891
Practice Address - Fax:561-586-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13087261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental