Provider Demographics
NPI:1942654710
Name:HERNANDEZ, EDGARDO ENRIQUE
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:ENRIQUE
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 1:17175 NE 20TH AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3273
Mailing Address - Country:US
Mailing Address - Phone:786-303-3334
Mailing Address - Fax:
Practice Address - Street 1:17175 NE 20TH AVE APT 8
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3273
Practice Address - Country:US
Practice Address - Phone:786-303-3334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22483124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist