Provider Demographics
NPI:1447257050
Name:HERNANDEZ, ELLIS I (DMD)
Entity type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:I
Last Name:HERNANDEZ
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:PO BOX 193392
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-3392
Mailing Address - Country:US
Mailing Address - Phone:787-781-3187
Mailing Address - Fax:787-782-5547
Practice Address - Street 1:1212 CALLE CADIZ
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00920-3841
Practice Address - Country:US
Practice Address - Phone:787-781-3187
Practice Address - Fax:787-782-5547
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-29
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice