Provider Demographics
NPI:1720218167
Name:LOPEZ, MICHAEL DOUGLAS JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DOUGLAS
Last Name:LOPEZ
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2257 JACKSBORO PIKE
Mailing Address - Street 2:
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-2904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2257 JACKSBORO PIKE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2904
Practice Address - Country:US
Practice Address - Phone:423-562-4766
Practice Address - Fax:423-562-3998
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9047122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist