Provider Demographics
NPI:1912524299
Name:HERNANDEZ RODRIGUEZ, WENDY (DMD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:
Last Name:HERNANDEZ RODRIGUEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 W TOLEDO AVE
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-7339
Mailing Address - Country:US
Mailing Address - Phone:305-200-9695
Mailing Address - Fax:
Practice Address - Street 1:2670 S FERDON BLVD STE 108
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5481
Practice Address - Country:US
Practice Address - Phone:850-634-0748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL250831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice