Provider Demographics
NPI:1841786977
Name:HERNANDEZ, LUIS MANUEL
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:MANUEL
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 OAK ST
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-2249
Mailing Address - Country:US
Mailing Address - Phone:562-479-8628
Mailing Address - Fax:
Practice Address - Street 1:4825 OAK ST
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2249
Practice Address - Country:US
Practice Address - Phone:562-479-8628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-01
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80912126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant