Provider Demographics
NPI:1720647324
Name:HERNANDEZ, JORGE ANDRES (DDS)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:ANDRES
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 1:455 AQUA CIR
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-2716
Mailing Address - Country:US
Mailing Address - Phone:920-243-3600
Mailing Address - Fax:
Practice Address - Street 1:1 NORTH ST
Practice Address - Street 2:
Practice Address - City:MARKESAN
Practice Address - State:WI
Practice Address - Zip Code:53946-8522
Practice Address - Country:US
Practice Address - Phone:920-398-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist