Provider Demographics
NPI:1013183193
Name:LOPEZ, SAMUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4049
Mailing Address - Country:US
Mailing Address - Phone:973-746-0922
Mailing Address - Fax:973-746-5230
Practice Address - Street 1:129 GROVE ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4049
Practice Address - Country:US
Practice Address - Phone:973-746-0922
Practice Address - Fax:973-746-5230
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18656122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist