1174849400 NPI number — FERNANDO B. FERNANDEZ, DDS APC

Table of content: (NPI 1174849400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174849400 NPI number — FERNANDO B. FERNANDEZ, DDS APC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FERNANDO B. FERNANDEZ, DDS APC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174849400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5740 E OLYMPIC BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COMMERCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90022-5120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-722-6360
Provider Business Mailing Address Fax Number:
323-722-6355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5740 E OLYMPIC BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMMERCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90022-5120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-722-6360
Provider Business Practice Location Address Fax Number:
323-722-6355
Provider Enumeration Date:
04/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FERNANDEZ
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
BARR
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
323-722-6360

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  49517 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1621125 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 44021 . This is a "PACIFICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 11894501 . This is a "DENTAL BENEFITS PROVIDERS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0007225604 . This is a "AETNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 130881 . This is a "GUARDIAN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 7022774 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: B4951701 . This is a "DELTA DENTAL HEALTHY FAMILIES PROGRAM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G9314501 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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