MEDICARE: DR. MANUEL G LOPEZ DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12998	FL
2	1223G0001X	General Practice Dentistry	DN12998	FL

General Provider Information

NPI Number	:	1053328211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MANUEL G LOPEZ DDS

Provider Business Mailing Address
First Line	:	3190 PONCE DE LEON BLVD
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-6826
Country	:	US
Telephone Number	:	305-774-7273
Fax Number	:

Provider Business Practice Location Address
First Line	:	3190 PONCE DE LEON BLVD
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-6826
Country	:	US
Telephone Number	:	305-774-7273
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	05/02/2018

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