Healthcare Provider Details

I. General information

NPI: 1487650164
Provider Name (Legal Business Name): TEODORO LOPEZ RIVERA D.M.D., MSCD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDIFICIO CLAUSELLS 129 CALLE VILLA SUITE 24
PONCE PR
00730
US

IV. Provider business mailing address

PO BOX 330707
PONCE PR
00733-0707
US

V. Phone/Fax

Practice location:
  • Phone: 787-844-1880
  • Fax: 787-844-5885
Mailing address:
  • Phone: 787-844-1880
  • Fax: 787-844-5885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number728
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: