Provider Demographics
NPI:1710610860
Name:HERNANDEZ, CARLOS GERARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:GERARD
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 KELLE DR APT 203
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8985
Mailing Address - Country:US
Mailing Address - Phone:260-388-1812
Mailing Address - Fax:
Practice Address - Street 1:2005 ROOSEVELT RD # B
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2746
Practice Address - Country:US
Practice Address - Phone:219-531-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013868A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice