Provider Demographics
NPI:1225529464
Name:CARLOS LOPEZ DIAZ DDS DENTAL CORPORATION
Entity Type:Organization
Organization Name:CARLOS LOPEZ DIAZ DDS DENTAL CORPORATION
Other - Org Name:SMY LIFE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:226-200-1900
Mailing Address - Street 1:19046 LA PUENTE RD
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792
Mailing Address - Country:US
Mailing Address - Phone:626-200-1900
Mailing Address - Fax:
Practice Address - Street 1:19046 LA PUENTE RD
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792
Practice Address - Country:US
Practice Address - Phone:626-200-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARLOS LOPEZ DIAZ DDS DENTAL CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101712122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty