Healthcare Provider Details

I. General information

NPI: 1245170828
Provider Name (Legal Business Name): AUSTIN GILBERTO LOPEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 CENTRAL CT
GREEN BAY WI
54311-6276
US

IV. Provider business mailing address

2040 CENTRAL CT
GREEN BAY WI
54311-6276
US

V. Phone/Fax

Practice location:
  • Phone: 920-633-3215
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6002205-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: