Provider Demographics
NPI:1669652152
Name:HERNANDEZ, JUAN CARLOS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:CARLOS
Other - Last Name:HERNANDEZ HUERTAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3705 OLD NORCROSS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4336
Mailing Address - Country:US
Mailing Address - Phone:347-228-4321
Mailing Address - Fax:770-813-1023
Practice Address - Street 1:3705 OLD NORCROSS RD STE 300
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4336
Practice Address - Country:US
Practice Address - Phone:770-813-0777
Practice Address - Fax:770-813-1023
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0136331223G0001X, 122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1669652152Medicaid