Provider Demographics
NPI:1639804453
Name:J BROGAN LOPEZ DDS PA
Entity Type:Organization
Organization Name:J BROGAN LOPEZ DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BROGAN
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-828-9261
Mailing Address - Street 1:1112 AUTUMN OAKS LN
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2218
Mailing Address - Country:US
Mailing Address - Phone:901-828-9261
Mailing Address - Fax:
Practice Address - Street 1:2414 S 58TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3827
Practice Address - Country:US
Practice Address - Phone:479-452-3368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental