Provider Demographics
NPI:1730145061
Name:LOPEZ, EUSTORGIO A (MD, DDS)
Entity Type:Individual
Prefix:
First Name:EUSTORGIO
Middle Name:A
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2018
Mailing Address - Country:US
Mailing Address - Phone:954-262-7153
Mailing Address - Fax:954-262-1793
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-7153
Practice Address - Fax:954-262-1793
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 131121223S0112X
FLME74506204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015641700Medicaid
FL2686961-00Medicaid
FL56845Medicare PIN
FLU69465Medicare UPIN
FL0756423-00Medicaid