Provider Demographics
NPI:1700011095
Name:HERNANDEZ, HERMINIO JESUS (DDS)
Entity Type:Individual
Prefix:
First Name:HERMINIO
Middle Name:JESUS
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 1:1400 NW 12TH AVE # 2005
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1003
Mailing Address - Country:US
Mailing Address - Phone:305-689-6725
Mailing Address - Fax:305-689-1113
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-689-6725
Practice Address - Fax:305-689-1113
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57747122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist