Provider Demographics
NPI:1760611412
Name:FERNANDEZ, BLANCA LILIA (DOCTOR OF DENTAL MED)
Entity Type:Individual
Prefix:DR
First Name:BLANCA
Middle Name:LILIA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:DOCTOR OF DENTAL MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5635 VINTAGE VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-5057
Mailing Address - Country:US
Mailing Address - Phone:863-647-1954
Mailing Address - Fax:863-647-1902
Practice Address - Street 1:5163 US HIGHWAY 98 S
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812
Practice Address - Country:US
Practice Address - Phone:330-475-3654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN186831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice