Provider Demographics
NPI:1467626234
Name:LOPEZ, YARISSA (DDS)
Entity Type:Individual
Prefix:
First Name:YARISSA
Middle Name:
Last Name: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 1:1429 BUCKNER ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-5408
Mailing Address - Country:US
Mailing Address - Phone:305-978-6759
Mailing Address - Fax:
Practice Address - Street 1:10246 KINGS HWY
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-3429
Practice Address - Country:US
Practice Address - Phone:540-625-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014130081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice