Provider Demographics
NPI:1760196695
Name:LOPEZ, MATTHEW D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
Last Name:LOPEZ
Suffix:
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 1:4322 RAVENSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-5630
Mailing Address - Country:US
Mailing Address - Phone:703-256-5870
Mailing Address - Fax:
Practice Address - Street 1:4322 RAVENSWORTH RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-5630
Practice Address - Country:US
Practice Address - Phone:703-256-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418253122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist