Provider Demographics
NPI:1649288721
Name:HERNANDEZ, IVIS A (DDS)
Entity type:Individual
Prefix:MS
First Name:IVIS
Middle Name:A
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:IVIS
Other - Middle Name:A
Other - Last Name:MORFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:10497 TOWN AND COUNTRY WAY
Mailing Address - Street 2:SUITE 914
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024
Mailing Address - Country:US
Mailing Address - Phone:713-468-5800
Mailing Address - Fax:713-468-2881
Practice Address - Street 1:10497 TOWN AND COUNTRY WAY
Practice Address - Street 2:SUITE 914
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024
Practice Address - Country:US
Practice Address - Phone:713-468-5800
Practice Address - Fax:713-468-5800
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX76-0421713OtherOLD TAX ID
TX15126OtherUNITED CONCORDIA