Provider Demographics
NPI:1467096479
Name:HERNANDEZ, MARIA ELIZABETH IGNACIO
Entity Type:Individual
Prefix:
First Name:MARIA ELIZABETH
Middle Name:IGNACIO
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 FAIR PARK AVE APT 115
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1946
Mailing Address - Country:US
Mailing Address - Phone:626-626-0653
Mailing Address - Fax:
Practice Address - Street 1:2604 S VERMONT AVE STE F
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-2298
Practice Address - Country:US
Practice Address - Phone:323-212-5495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA90778126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant