Provider Demographics
NPI:1861119059
Name:HERNANDEZ AVALOS, MIGUEL ALEJANDRO (DDS)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ALEJANDRO
Last Name:HERNANDEZ AVALOS
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 1:38 VIA RICARDO
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-7001
Mailing Address - Country:US
Mailing Address - Phone:805-236-1611
Mailing Address - Fax:
Practice Address - Street 1:30423 CANWOOD ST STE 121
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4314
Practice Address - Country:US
Practice Address - Phone:818-889-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1074941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice