Provider Demographics
NPI:1770654238
Name:HERNANDEZ, GREDELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREDELL
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 W CREST AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-6839
Mailing Address - Country:US
Mailing Address - Phone:813-877-4638
Mailing Address - Fax:813-872-0689
Practice Address - Street 1:2509 W CREST AVE STE 4
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-6839
Practice Address - Country:US
Practice Address - Phone:813-877-4638
Practice Address - Fax:813-872-0689
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 13251122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist