Provider Demographics
NPI:1417089459
Name:DE LOPEZ, LAURA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:DE LOPEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:MARIA
Other - Middle Name:LAURA
Other - Last Name:DE LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1320 N GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3808
Mailing Address - Country:US
Mailing Address - Phone:909-623-4487
Mailing Address - Fax:909-623-4645
Practice Address - Street 1:1320 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3808
Practice Address - Country:US
Practice Address - Phone:909-623-4487
Practice Address - Fax:909-623-4645
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA478741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA47874OtherLICENSE #
CAD47874OtherMEDI-CAL DENTAL PROGRAM