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General NPI Number Information
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NPI Number | 1821739749
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Entity Type | Individual
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Provider Name | DIANA LOPEZ
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Gender | Female
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Dates
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Enumeration Date | 04/05/2022
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Last Update Date | 08/14/2025
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Provider Practice Location Address
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Address Line | 2111 E OAKLAND AVE STE D
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City | BLOOMINGTON
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State | IL
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Zip | 61701-5783
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Country | US
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Telephone | 309-663-6564
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Fax |
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Provider Business Mailing Address
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Address Line | 2111 E OAKLAND AVE STE D
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City | BLOOMINGTON
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State | IL
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Zip | 61701-5783
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Country | US
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Telephone | 309-663-6564
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 019036011
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 021003464
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License Number State | IL
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