Provider Demographics
NPI:1215712070
Name:FERNANDEZ, MARICARMEN I
Entity type:Individual
Prefix:
First Name:MARICARMEN
Middle Name:
Last Name:FERNANDEZ
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HIGH OAKS PATH
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:MA
Mailing Address - Zip Code:01450-1037
Mailing Address - Country:US
Mailing Address - Phone:978-735-8431
Mailing Address - Fax:
Practice Address - Street 1:NICHOLS RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-1914
Practice Address - Country:US
Practice Address - Phone:978-878-8110
Practice Address - Fax:978-627-8349
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL15589122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist