Provider Demographics
NPI:1770153447
Name:HERNANDEZ, MARIO ANTONIO (DDS)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:ANTONIO
Last Name:HERNANDEZ
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 1:10920 W FLAGLER ST STE 205
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1243
Mailing Address - Country:US
Mailing Address - Phone:786-208-2950
Mailing Address - Fax:
Practice Address - Street 1:10920 W FLAGLER ST STE 205
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1243
Practice Address - Country:US
Practice Address - Phone:786-452-1922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN261411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice