Provider Demographics
NPI:1396830592
Name:LOPEZ, MIGUEL ANGEL (JR)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:JR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19130 CENTRE ROSE BLVD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558
Mailing Address - Country:US
Mailing Address - Phone:813-926-9532
Mailing Address - Fax:
Practice Address - Street 1:3131 NORTH BOULEVARD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603
Practice Address - Country:US
Practice Address - Phone:813-229-7427
Practice Address - Fax:813-228-8832
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice