Provider Demographics
NPI:1700927340
Name:FERNANDEZ, OMAR J (DDS)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:J
Last Name:FERNANDEZ
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 1:10720 LA REINA AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3419
Mailing Address - Country:US
Mailing Address - Phone:626-216-2258
Mailing Address - Fax:
Practice Address - Street 1:811 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4009
Practice Address - Country:US
Practice Address - Phone:213-383-3314
Practice Address - Fax:213-383-0621
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA534491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice