Provider Demographics
NPI:1124830989
Name:HERNANDEZ, CUTBERTO A SR
Entity type:Individual
Prefix:DR
First Name:CUTBERTO
Middle Name:A
Last Name:HERNANDEZ
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4927
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349-4927
Mailing Address - Country:US
Mailing Address - Phone:928-514-6545
Mailing Address - Fax:
Practice Address - Street 1:AVENIDA LIBERTAD Y CALLE 17 #1608
Practice Address - Street 2:
Practice Address - City:SAN LUIS RIO COLORADO
Practice Address - State:SONORA
Practice Address - Zip Code:83447
Practice Address - Country:MX
Practice Address - Phone:928-514-6545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ38726721223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty