Provider Demographics
NPI:1477763134
Name:FERNANDEZ, ROBERT MARIO (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MARIO
Last Name:FERNANDEZ
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 1:256 N SAN MATEO DR
Mailing Address - Street 2:#5
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2624
Mailing Address - Country:US
Mailing Address - Phone:650-344-7121
Mailing Address - Fax:650-347-7763
Practice Address - Street 1:256 N SAN MATEO DR
Practice Address - Street 2:#5
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2624
Practice Address - Country:US
Practice Address - Phone:650-344-7121
Practice Address - Fax:650-347-7763
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26756122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist