Healthcare Provider Details

I. General information

NPI: 1538790217
Provider Name (Legal Business Name): SANTIAGO LOPEZ C DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 NW 100TH AVE
PLANTATION FL
33324-7034
US

IV. Provider business mailing address

131 NW 100TH AVE
PLANTATION FL
33324-7034
US

V. Phone/Fax

Practice location:
  • Phone: 954-476-4537
  • Fax: 954-476-7734
Mailing address:
  • Phone: 954-476-4537
  • Fax: 954-476-7734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SANTIAGO LOPEZ
Title or Position: OWNER/CLINICAL DIRECTOR
Credential: DDS
Phone: 954-476-4537