Provider Demographics
NPI:1629197637
Name:FERNANDEZ, CARLOS ENRIQUE (DMD, PA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ENRIQUE
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8539 NW 186TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-2555
Mailing Address - Country:US
Mailing Address - Phone:305-829-2160
Mailing Address - Fax:305-829-3989
Practice Address - Street 1:8539 NW 186TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-2555
Practice Address - Country:US
Practice Address - Phone:305-829-2160
Practice Address - Fax:305-829-3989
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00126921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice