Provider Demographics
NPI:1205164530
Name:HERNANDEZ, OSVALDO (DDS)
Entity type:Individual
Prefix:
First Name:OSVALDO
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 WISE OAK LN
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-7139
Mailing Address - Country:US
Mailing Address - Phone:209-505-8944
Mailing Address - Fax:
Practice Address - Street 1:230 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2517
Practice Address - Country:US
Practice Address - Phone:209-940-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59009122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist