Healthcare Provider Details

I. General information

NPI: 1053362590
Provider Name (Legal Business Name): JOSEPH WONG LOPEZ D.M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 DUKE ST STE A
ALEXANDRIA VA
22314-4555
US

IV. Provider business mailing address

3223 DUKE ST STE A
ALEXANDRIA VA
22314-4555
US

V. Phone/Fax

Practice location:
  • Phone: 571-257-5744
  • Fax: 571-535-3533
Mailing address:
  • Phone: 571-257-5744
  • Fax: 571-535-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS036367
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401414156
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number14406
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: