=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306040597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDWARD LOPEZ AMERICA DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 04/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2716 N BROADWAY STE 211
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90031-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-221-5931
-----------------------------------------------------
Fax | 323-221-6952
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2716 N BROADWAY STE 211
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90031-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-221-5931
-----------------------------------------------------
Fax | 323-221-6952
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | NINOSKA ESPINOZA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-221-5931
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 29354
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------