Provider Demographics
NPI:1730399619
Name:FERNANDEZ, JOSE G (DDS)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:G
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 E SOUTHERN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-3086
Mailing Address - Country:US
Mailing Address - Phone:602-276-6400
Mailing Address - Fax:602-305-8745
Practice Address - Street 1:444 E SOUTHERN AVE STE 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-3086
Practice Address - Country:US
Practice Address - Phone:602-276-6400
Practice Address - Fax:602-305-8745
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5345122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist