Provider Demographics
NPI:1316186562
Name:MAROON-LOPEZ, CARMEN DENISE (DDS)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:DENISE
Last Name:MAROON-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 1:2648 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-4664
Mailing Address - Country:US
Mailing Address - Phone:619-423-5200
Mailing Address - Fax:619-423-2706
Practice Address - Street 1:2648 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-4664
Practice Address - Country:US
Practice Address - Phone:619-423-5200
Practice Address - Fax:619-423-2706
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD40672122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist