Provider Demographics
NPI:1578581641
Name:LOPEZ, MICHAEL JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 MIRAMONTE AVE
Mailing Address - Street 2:SUITE #8
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-3766
Mailing Address - Country:US
Mailing Address - Phone:650-961-5808
Mailing Address - Fax:650-961-5823
Practice Address - Street 1:1704 MIRAMONTE AVE
Practice Address - Street 2:SUITE #8
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-3766
Practice Address - Country:US
Practice Address - Phone:650-961-5808
Practice Address - Fax:650-961-5823
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA270231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27023OtherCALIFORNIA LICENSE
644241OtherUNITED CONCORDIA INS.