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General NPI Number Information
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NPI Number | 1225529464
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Entity Type | Organization
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Legal Business Name | CARLOS LOPEZ DIAZ DDS DENTAL CORPORATION
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Dates
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Enumeration Date | 05/23/2018
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Last Update Date | 05/23/2018
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Provider Practice Location Address
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Address Line | 19046 LA PUENTE RD
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City | WEST COVINA
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State | CA
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Zip | 91792
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Country | US
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Telephone | 626-200-1900
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Fax |
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Provider Business Mailing Address
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Address Line | 19046 LA PUENTE RD
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City | WEST COVINA
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State | CA
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Zip | 91792
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Country | US
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Telephone | 626-200-1900
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CARLOS LOPEZ DIAZ
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Credential | DDS
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Telephone | 226-200-1900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 101712
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License Number State | CA
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