Healthcare Provider Details

I. General information

NPI: 1881031888
Provider Name (Legal Business Name): CARLOS LOPEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 DE MARZO #2952
CIUDAD JUAREZ CHIHUAHUA
32330
MX

IV. Provider business mailing address

PO BOX 12385
EL PASO TX
79913-0385
US

V. Phone/Fax

Practice location:
  • Phone: 011526566113656
  • Fax:
Mailing address:
  • Phone: 915-726-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2932056
License Number StateZZ

VIII. Authorized Official

Name: CARLOS E. LOPEZ
Title or Position: OWNER
Credential:
Phone: 011526566113656