Provider Demographics
NPI:1235424904
Name:FERNANDEZ, MARIOLY (DMD)
Entity type:Individual
Prefix:DR
First Name:MARIOLY
Middle Name:
Last Name:FERNANDEZ
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 1:4355 W 16AVE
Mailing Address - Street 2:205A
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012
Mailing Address - Country:US
Mailing Address - Phone:395-824-9199
Mailing Address - Fax:305-824-8885
Practice Address - Street 1:4355 W 16TH AVE
Practice Address - Street 2:205A
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7666
Practice Address - Country:US
Practice Address - Phone:305-824-9199
Practice Address - Fax:305-824-8885
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist