Healthcare Provider Details

I. General information

NPI: 1033523642
Provider Name (Legal Business Name): MARCO LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 10/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GYPSY LN FL 3
YOUNGSTOWN OH
44504-1315
US

IV. Provider business mailing address

500 GYPSY LN FL 3
YOUNGSTOWN OH
44504-1315
US

V. Phone/Fax

Practice location:
  • Phone: 330-884-3058
  • Fax:
Mailing address:
  • Phone: 330-884-3058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3423
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401415354
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: