Provider Demographics
NPI:1376091959
Name:LOPEZ, DOMINIQUE ANTHONY (LMT)
Entity Type:Individual
Prefix:MR
First Name:DOMINIQUE
Middle Name:ANTHONY
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WILLIAM ST STE 101
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-1903
Mailing Address - Country:US
Mailing Address - Phone:914-328-3750
Mailing Address - Fax:914-328-6945
Practice Address - Street 1:2 WILLIAM ST STE 101
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-1903
Practice Address - Country:US
Practice Address - Phone:914-328-3750
Practice Address - Fax:914-328-6945
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011850-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist