MEDICARE: DR. JOSEPH WONG LOPEZ D.M.D., M.P.H.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	DS036367	PA
2	1223P0221X	Pediatric Dentistry	0401414156	VA
3	1223P0221X	Pediatric Dentistry	14406	MD

General Provider Information

NPI Number	:	1053362590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH WONG LOPEZ D.M.D., M.P.H.

Provider Business Mailing Address
First Line	:	3223 DUKE ST STE A
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-4555
Country	:	US
Telephone Number	:	571-257-5744
Fax Number	:	571-535-3533

Provider Business Practice Location Address
First Line	:	3223 DUKE ST STE A
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-4555
Country	:	US
Telephone Number	:	571-257-5744
Fax Number	:	571-535-3533

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	08/17/2021

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