Provider Demographics
NPI:1790050474
Name:HERNANDEZ, NICOLE (DDS, MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 W GRAND CENTRAL AVE UNIT 814
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-1978
Mailing Address - Country:US
Mailing Address - Phone:813-751-5958
Mailing Address - Fax:
Practice Address - Street 1:2711 TAMPA RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3336
Practice Address - Country:US
Practice Address - Phone:727-786-1631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN248401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty