Provider Demographics
NPI:1609654441
Name:VILLA LOPEZ, DENISSE EVELYN
Entity Type:Individual
Prefix:
First Name:DENISSE
Middle Name:EVELYN
Last Name:VILLA LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4375 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3702
Mailing Address - Country:US
Mailing Address - Phone:770-939-7576
Mailing Address - Fax:770-939-0212
Practice Address - Street 1:4375 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-3702
Practice Address - Country:US
Practice Address - Phone:770-939-7576
Practice Address - Fax:770-939-0212
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002738156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician