Provider Demographics
NPI:1134514466
Name:LOPEZ, JENNIFER M (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 95TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SURFSIDE
Mailing Address - State:FL
Mailing Address - Zip Code:33154-2807
Mailing Address - Country:US
Mailing Address - Phone:305-865-0453
Mailing Address - Fax:
Practice Address - Street 1:260 95TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SURFSIDE
Practice Address - State:FL
Practice Address - Zip Code:33154-2807
Practice Address - Country:US
Practice Address - Phone:305-865-0453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21443122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist