Healthcare Provider Details

I. General information

NPI: 1538281852
Provider Name (Legal Business Name): JOSE E LOPEZ D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 AVE JESUS T PINERO
SAN JUAN PR
00918-4004
US

IV. Provider business mailing address

264 AVE JESUS T PINERO
SAN JUAN PR
00918-4004
US

V. Phone/Fax

Practice location:
  • Phone: 787-781-0638
  • Fax:
Mailing address:
  • Phone: 787-781-0638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD 729
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: