Provider Demographics
NPI:1225494180
Name:LOPEZ, RAQUEL LISBET (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:LISBET
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 CILIOTTA LN
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3435
Mailing Address - Country:US
Mailing Address - Phone:516-380-1441
Mailing Address - Fax:
Practice Address - Street 1:1247 SUFFOLK AVE STE 2
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4518
Practice Address - Country:US
Practice Address - Phone:631-434-7156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0491561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice