Provider Demographics
NPI:1487820296
Name:HERNANDEZ, MARIO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:HERNANDEZ
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 1:1870 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
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00130871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice