Provider Demographics
NPI:1104207653
Name:SERGIO E LOPEZ, DDS, PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:SERGIO E LOPEZ, DDS, PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-212-3662
Mailing Address - Street 1:4217 COLBATH AVE
Mailing Address - Street 2:APT. 330-B
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503
Mailing Address - Country:US
Mailing Address - Phone:956-212-3662
Mailing Address - Fax:
Practice Address - Street 1:1507 SOUTH MCCOLL ROAD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78541
Practice Address - Country:US
Practice Address - Phone:956-212-3662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX271291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty