MEDICARE: JENNIFER M LOPEZ DMD

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	122300000X	Dentist	DN21443	FL

General Provider Information

NPI Number	:	1134514466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER M LOPEZ DMD

Provider Business Mailing Address
First Line	:	260 95TH ST
Second Line	:	SUITE 202
City	:	SURFSIDE
State	:	FL
Zip	:	33154-2807
Country	:	US
Telephone Number	:	305-865-0453
Fax Number	:

Provider Business Practice Location Address
First Line	:	260 95TH ST
Second Line	:	SUITE 202
City	:	SURFSIDE
State	:	FL
Zip	:	33154-2807
Country	:	US
Telephone Number	:	305-865-0453
Fax Number	:

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

Provider Enumeration Date	:	04/02/2015
Last Update Date	:	11/18/2016

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