Healthcare Provider Details

I. General information

NPI: 1023362811
Provider Name (Legal Business Name): EUSTORGIO A LOPEZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1548 NW 208TH WAY
PEMBROKE PINES FL
33029-2306
US

IV. Provider business mailing address

1548 NW 208TH WAY
PEMBROKE PINES FL
33029-2306
US

V. Phone/Fax

Practice location:
  • Phone: 786-375-1449
  • Fax: 954-337-0356
Mailing address:
  • Phone: 786-375-1449
  • Fax: 954-337-0356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberME74506
License Number StateFL

VIII. Authorized Official

Name: DR. EUSTORGIO A LOPEZ
Title or Position: PRESIDENT
Credential: MD, DDS
Phone: 786-375-1449