Healthcare Provider Details

I. General information

NPI: 1609896752
Provider Name (Legal Business Name): JUAN CARLOS LOPEZ D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW 16TH ST DENTAL SERVICE (160), VA MEDICAL CENTER
MIAMI FL
33125-1624
US

IV. Provider business mailing address

1201 NW 16TH ST DENTAL SERVICE (160), VA MEDICAL CENTER
MIAMI FL
33125-1624
US

V. Phone/Fax

Practice location:
  • Phone: 305-575-3146
  • Fax: 305-575-3373
Mailing address:
  • Phone: 305-575-3146
  • Fax: 305-575-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN15576
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: