Provider Demographics
NPI:1538393152
Name:FERNANDEZ, JUAN CARLOS (DDS, MS)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 SAWDUST RD
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2245
Mailing Address - Country:US
Mailing Address - Phone:281-292-4400
Mailing Address - Fax:281-924-4422
Practice Address - Street 1:566 SAWDUST RD
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-2245
Practice Address - Country:US
Practice Address - Phone:281-292-4400
Practice Address - Fax:281-292-4442
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242231223P0700X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1245628304Medicaid
TX345693101Medicaid