Provider Demographics
NPI:1699217695
Name:MAYRA LOPEZ
Entity Type:Organization
Organization Name:MAYRA LOPEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:915-249-9121
Mailing Address - Street 1:BLVD. GOMEZ MORIN #8569
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:JUAREZ
Mailing Address - State:CHIHUAHUA
Mailing Address - Zip Code:32548
Mailing Address - Country:MX
Mailing Address - Phone:915-249-9121
Mailing Address - Fax:
Practice Address - Street 1:BLVD. GOMEZ MORIN #8569
Practice Address - Street 2:SUITE 6A
Practice Address - City:JUAREZ
Practice Address - State:CHIHUAHUA
Practice Address - Zip Code:32548
Practice Address - Country:MX
Practice Address - Phone:915-249-9121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ3900513122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty