Provider Demographics
NPI:1740971381
Name:FERNANDEZ, DYLAN (DMD)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21451 BIRDHOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-3359
Mailing Address - Country:US
Mailing Address - Phone:949-302-3726
Mailing Address - Fax:
Practice Address - Street 1:13334 LIMONITE AVE STE 120
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-7257
Practice Address - Country:US
Practice Address - Phone:951-228-9294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109123122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty