Provider Demographics
NPI:1497532840
Name:LOPEZ, JASMINE RENEE MIRANDA (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASMINE RENEE
Middle Name:MIRANDA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 E MAIN ST APT 6
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-2180
Mailing Address - Country:US
Mailing Address - Phone:732-208-9624
Mailing Address - Fax:
Practice Address - Street 1:223 S PLEASANT AVE STE 303
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-2188
Practice Address - Country:US
Practice Address - Phone:814-445-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0443551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice