Provider Demographics
NPI:1689081242
Name:LOPEZ, MELVIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 PRESIDENT ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5433
Mailing Address - Country:US
Mailing Address - Phone:386-328-7638
Mailing Address - Fax:386-328-9644
Practice Address - Street 1:2503 PRESIDENT ST
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-5433
Practice Address - Country:US
Practice Address - Phone:386-328-7638
Practice Address - Fax:386-328-9644
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN208731223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015271300Medicaid