Provider Demographics
NPI:1740664432
Name:HERNANDEZ, FRED JR (DDS)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:HERNANDEZ
Suffix:JR
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 1:313 W PARKER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELKHART
Mailing Address - State:TX
Mailing Address - Zip Code:75839-7612
Mailing Address - Country:US
Mailing Address - Phone:903-764-5531
Mailing Address - Fax:903-764-0343
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4780
Practice Address - Country:US
Practice Address - Phone:903-729-7286
Practice Address - Fax:903-729-6395
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice