Provider Demographics
NPI:1619523560
Name:ACOSTA HERNANDEZ, MANUEL ALEJANDRO (DDS)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:ALEJANDRO
Last Name:ACOSTA 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 1:12900 BROXTON BAY DR APT 1128
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-8525
Mailing Address - Country:US
Mailing Address - Phone:954-655-9958
Mailing Address - Fax:
Practice Address - Street 1:651 NAUTICA DR UNIT 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7222
Practice Address - Country:US
Practice Address - Phone:904-423-4014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL245131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice