Healthcare Provider Details

I. General information

NPI: 1770504771
Provider Name (Legal Business Name): WAYNK K LOPEZ D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 NARRAGANSETT TRL
BUXTON ME
04093-6505
US

IV. Provider business mailing address

440 NARRAGANSETT TRL
BUXTON ME
04093-6505
US

V. Phone/Fax

Practice location:
  • Phone: 207-929-3900
  • Fax: 207-929-3907
Mailing address:
  • Phone: 207-929-3900
  • Fax: 207-929-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2155
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: