Basic Information
| Provider Information | |||||||||
| NPI: | 1548548845 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | MARINA | ||||||||
| MiddleName: | ALISSA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 MCHUGH BLVD PSC 20130 | ||||||||
| Address2: | COMMANDING OFFICER, 2D DENBN/NDC | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285400130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518036 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 MCHUGH BLVD PSC 20130 | ||||||||
| Address2: | COMMANDING OFFICER, 2D DENBN/NDC | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285400130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2011 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE60238228 | WA | Y | Dental Providers | Dentist |
No ID Information.