Provider Demographics
NPI:1023362811
Name:EUSTORGIO A LOPEZ LLC
Entity Type:Organization
Organization Name:EUSTORGIO A LOPEZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUSTORGIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:786-375-1449
Mailing Address - Street 1:1548 NW 208TH WAY
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-2306
Mailing Address - Country:US
Mailing Address - Phone:786-375-1449
Mailing Address - Fax:954-337-0356
Practice Address - Street 1:1548 NW 208TH WAY
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2306
Practice Address - Country:US
Practice Address - Phone:786-375-1449
Practice Address - Fax:954-337-0356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME745061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty