Healthcare Provider Details

I. General information

NPI: 1700915808
Provider Name (Legal Business Name): JOSE L. LOPEZ, DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3490 PALM AVE
SAN DIEGO CA
92154-1664
US

IV. Provider business mailing address

3490 PALM AVE
SAN DIEGO CA
92154-1664
US

V. Phone/Fax

Practice location:
  • Phone: 619-423-1351
  • Fax:
Mailing address:
  • Phone: 619-423-1351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number44013
License Number StateCA

VIII. Authorized Official

Name: DR. JOSE L. LOPEZ
Title or Position: PRESIDENT OF CORPORATION
Credential: DDS
Phone: 619-423-1351