Provider Demographics
NPI:1760267199
Name:HERNANDEZ, KRYSTAL MIYENIA (RDH)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MIYENIA
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NE 53RD ST APT 3003
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-1884
Mailing Address - Country:US
Mailing Address - Phone:580-817-0773
Mailing Address - Fax:
Practice Address - Street 1:1024 SW 104TH ST UNIT B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2990
Practice Address - Country:US
Practice Address - Phone:405-679-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4695124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist