MEDICARE: DIEGO ALFONSO LOPEZ DMD

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	1223G0001X	General Practice Dentistry	38653	TX

General Provider Information

NPI Number	:	1396475505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIEGO ALFONSO LOPEZ DMD

Provider Business Mailing Address
First Line	:	8142 CACTUS BEND DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78254-4537
Country	:	US
Telephone Number	:	210-630-7160
Fax Number	:

Provider Business Practice Location Address
First Line	:	11831 CULEBRA RD STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-4578
Country	:	US
Telephone Number	:	210-625-5353
Fax Number	:

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

Provider Enumeration Date	:	06/13/2022
Last Update Date	:	06/13/2022

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