Provider Demographics
NPI:1649565557
Name:HERNANDEZ, JERRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
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 1:7484 UNIVERSITY AVE
Mailing Address - Street 2:STE.#150
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-6063
Mailing Address - Country:US
Mailing Address - Phone:619-460-2500
Mailing Address - Fax:619-462-3169
Practice Address - Street 1:7484 UNIVERSITY AVE
Practice Address - Street 2:STE. 150
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-6063
Practice Address - Country:US
Practice Address - Phone:619-460-2500
Practice Address - Fax:619-462-3169
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014132491223G0001X
CA605391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice