Provider Demographics
NPI:1962654756
Name:FERNANDO, MARCIA M (RDHAP)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:M
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11078 MATINAL CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1260
Mailing Address - Country:US
Mailing Address - Phone:858-705-0447
Mailing Address - Fax:858-451-2094
Practice Address - Street 1:11078 MATINAL CIR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1260
Practice Address - Country:US
Practice Address - Phone:858-705-0447
Practice Address - Fax:858-451-2094
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA214124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist