Provider Demographics
NPI:1770071961
Name:HERNANDEZ, BO MARIE (RDA)
Entity type:Individual
Prefix:
First Name:BO
Middle Name:MARIE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7005 N CHESTNUT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0348
Mailing Address - Country:US
Mailing Address - Phone:559-299-3949
Mailing Address - Fax:559-299-7880
Practice Address - Street 1:7005 N CHESTNUT AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0348
Practice Address - Country:US
Practice Address - Phone:559-299-3949
Practice Address - Fax:559-299-7880
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA72473126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant