Provider Demographics
NPI:1225231046
Name:LOPEZ, JUAN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:R
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 1:6941 W GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5311
Mailing Address - Country:US
Mailing Address - Phone:580-536-9647
Mailing Address - Fax:580-536-4075
Practice Address - Street 1:6941 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5311
Practice Address - Country:US
Practice Address - Phone:580-536-9647
Practice Address - Fax:580-536-4075
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK05022122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist