MEDICARE: JOSE LUIS LOPEZ DDS, INC.

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1033626247	OTHER	CA	INSURERS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497424592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSE LUIS LOPEZ DDS, INC.

Provider Business Mailing Address
First Line	:	3127 BALDWIN PARK BLVD STE D
Second Line	:
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-4754
Country	:	US
Telephone Number	:	626-962-3500
Fax Number	:	626-962-3551

Provider Business Practice Location Address
First Line	:	3127 BALDWIN PARK BLVD STE D
Second Line	:
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-4754
Country	:	US
Telephone Number	:	626-962-3500
Fax Number	:	626-962-3551

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. JOSE LUIS LOPEZ BENDEZU
Credential	:	DDS
Telephone Number	:	714-429-6734

Provider Enumeration Date	:	09/10/2021
Last Update Date	:	09/10/2021

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