MEDICARE: DR. JESUS RICARDO LOPEZ D.D.S.

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	1223G0001X	General Practice Dentistry	D4903	AZ

General Provider Information

NPI Number	:	1639176035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESUS RICARDO LOPEZ D.D.S.

Provider Business Mailing Address
First Line	:	6375 E TANQUE VERDE RD
Second Line	:	SUITE 30
City	:	TUCSON
State	:	AZ
Zip	:	85715-3852
Country	:	US
Telephone Number	:	520-886-8090
Fax Number	:	520-886-8274

Provider Business Practice Location Address
First Line	:	6375 E TANQUE VERDE RD
Second Line	:	SUITE 30
City	:	TUCSON
State	:	AZ
Zip	:	85715-3852
Country	:	US
Telephone Number	:	520-886-8090
Fax Number	:	520-886-8274

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

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	07/29/2015

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