Provider Demographics
NPI:1053328211
Name:LOPEZ, MANUEL G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:G
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3190 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-6826
Mailing Address - Country:US
Mailing Address - Phone:305-774-7273
Mailing Address - Fax:
Practice Address - Street 1:3190 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-6826
Practice Address - Country:US
Practice Address - Phone:305-774-7273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12998122300000X
FLDN129981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist