=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316102585
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAQUEL L LOPEZ DDS FAMILY DENTISTRY P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2008
-----------------------------------------------------
Last Update Date | 07/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1247 SUFFOLK AVE SUITE #2
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11717-4518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-434-7156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 CILIOTTA LN
-----------------------------------------------------
City | PORT JEFFERSON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11776-3435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-380-1441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RAQUEL L LOPEZ
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 516-380-1441
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 049156
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------