Provider Demographics
NPI:1629420666
Name:GLENDALY FERNANDEZ, PLLC
Entity Type:Organization
Organization Name:GLENDALY FERNANDEZ, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENDALY
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:940-696-9701
Mailing Address - Street 1:2515 E ELLIOTT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-3708
Mailing Address - Country:US
Mailing Address - Phone:940-696-9701
Mailing Address - Fax:
Practice Address - Street 1:2515 E ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-3708
Practice Address - Country:US
Practice Address - Phone:940-696-9701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX316631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty