Provider Demographics
NPI:1710099817
Name:HERNANDEZ, MIGUEL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:R
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 1:1030 W GORDON AVE
Mailing Address - Street 2:STE. A
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-4514
Mailing Address - Country:US
Mailing Address - Phone:229-432-9555
Mailing Address - Fax:229-432-0907
Practice Address - Street 1:1030 W GORDON AVE
Practice Address - Street 2:STE A
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-4514
Practice Address - Country:US
Practice Address - Phone:229-432-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL52731223G0001X
GADN0132921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009933951Medicaid
AL009935939Medicaid
AL009976865Medicaid
AL009927125Medicaid
GA129513623AMedicaid