Healthcare Provider Details

I. General information

NPI: 1457580185
Provider Name (Legal Business Name): RICARDO LOPEZ REY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-6857
  • Fax: 305-326-8328
Mailing address:
  • Phone: 305-585-6857
  • Fax: 305-326-8328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDPR 805
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN 19693
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: