Provider Demographics
NPI:1740416379
Name:HERNANDEZ-GIL, JOSE A (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:A
Last Name:HERNANDEZ-GIL
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:PO BOX 403
Mailing Address - Street 2:
Mailing Address - City:TESUQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87574-0403
Mailing Address - Country:US
Mailing Address - Phone:505-780-8286
Mailing Address - Fax:505-780-8286
Practice Address - Street 1:4577 S 4000 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-6222
Practice Address - Country:US
Practice Address - Phone:808-966-0900
Practice Address - Fax:801-966-5046
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HICSDT-141223G0001X
NMDD 19271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8677334-9922OtherUTAH DENTAL LICENSE
NMDD1927OtherDENTAL LICENSE