Healthcare Provider Details

I. General information

NPI: 1730145061
Provider Name (Legal Business Name): EUSTORGIO A. LOPEZ M.D., D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/09/2023
Certification Date: 07/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

IV. Provider business mailing address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-7153
  • Fax: 954-262-1793
Mailing address:
  • Phone: 954-262-7153
  • Fax: 954-262-1793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN 13112
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME74506
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: