Provider Demographics
NPI:1326178518
Name:LOPEZ, MANUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
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 1:280 CONCORD PKWY S STE 110A
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-2704
Mailing Address - Country:US
Mailing Address - Phone:704-920-1070
Mailing Address - Fax:
Practice Address - Street 1:280 CONCORD PKWY S STE 110A
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-2704
Practice Address - Country:US
Practice Address - Phone:704-920-1070
Practice Address - Fax:704-920-1071
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990177Medicaid
NC90177OtherBCBS
NC90177OtherBCBS