Provider Demographics
NPI:1619382298
Name:LOPEZ, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17543 HIBISCUS ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-5036
Mailing Address - Country:US
Mailing Address - Phone:909-927-9177
Mailing Address - Fax:
Practice Address - Street 1:17543 HIBISCUS ST
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-5036
Practice Address - Country:US
Practice Address - Phone:909-927-9177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant