Healthcare Provider Details

I. General information

NPI: 1255408449
Provider Name (Legal Business Name): GLORIANA M LOPEZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 OVERSEAS HWY
MARATHON FL
33050-2239
US

IV. Provider business mailing address

224 29TH STREET OCEAN
MARATHON FL
33050-2218
US

V. Phone/Fax

Practice location:
  • Phone: 305-743-4000
  • Fax:
Mailing address:
  • Phone: 512-970-4919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17431
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN9664
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN009754
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: