Provider Demographics
NPI:1700541521
Name:FERNANDEZ, REYNALDO DELA ROSA
Entity Type:Individual
Prefix:DR
First Name:REYNALDO
Middle Name:DELA ROSA
Last Name:FERNANDEZ
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 1:1131 W SAN BERNARDINO RD
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-4108
Mailing Address - Country:US
Mailing Address - Phone:626-967-3599
Mailing Address - Fax:626-732-6232
Practice Address - Street 1:1131 W SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-4108
Practice Address - Country:US
Practice Address - Phone:626-967-3599
Practice Address - Fax:626-732-6232
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA339251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice