Provider Demographics
NPI:1851688584
Name:HERNANDEZ, JASON (DMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2018
Mailing Address - Country:US
Mailing Address - Phone:860-450-7471
Mailing Address - Fax:860-450-9808
Practice Address - Street 1:40 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2018
Practice Address - Country:US
Practice Address - Phone:860-450-7471
Practice Address - Fax:860-450-9808
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0108291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice