Provider Demographics
NPI:1104956317
Name:FERNANDEZ, JAIME (DDS)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
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 1:10106 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-4907
Mailing Address - Country:US
Mailing Address - Phone:714-962-7797
Mailing Address - Fax:714-965-3766
Practice Address - Street 1:10106 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-4907
Practice Address - Country:US
Practice Address - Phone:714-962-7797
Practice Address - Fax:714-965-3766
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA439541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice