Provider Demographics
NPI:1083931729
Name:SERGIO M. LOPEZ, D.D.S.,P. L.L.C.
Entity Type:Organization
Organization Name:SERGIO M. LOPEZ, D.D.S.,P. L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-513-5041
Mailing Address - Street 1:3102 W WATERS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2882
Mailing Address - Country:US
Mailing Address - Phone:813-374-2441
Mailing Address - Fax:813-513-2925
Practice Address - Street 1:3102 W WATERS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2882
Practice Address - Country:US
Practice Address - Phone:813-374-2441
Practice Address - Fax:813-513-2925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18229261QD0000X
CO9125122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013389200Medicaid
CO44821026Medicaid
FL007861100Medicaid