Provider Demographics
NPI:1508228057
Name:FERNANDEZ, STEPHANIE AMANDA (RDH)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:AMANDA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 CUTLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3935
Mailing Address - Country:US
Mailing Address - Phone:505-881-1234
Mailing Address - Fax:
Practice Address - Street 1:4400 CUTLER AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3935
Practice Address - Country:US
Practice Address - Phone:505-881-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH4076124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist