Provider Demographics
NPI:1558914705
Name:LOPEZ-ISA, BIANCA (DDS)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:LOPEZ-ISA
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 1:4613 W LONGFELLOW AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-7624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13018 US 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7420
Practice Address - Country:US
Practice Address - Phone:813-280-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN244321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice