Provider Demographics
NPI:1861471682
Name:LOPEZ, JUAN PEDRO (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:PEDRO
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 1:555 WILLARD AVE
Mailing Address - Street 2:VA DENTAL CLINIC
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2631
Mailing Address - Country:US
Mailing Address - Phone:860-667-6781
Mailing Address - Fax:860-667-6827
Practice Address - Street 1:555 WILLARD AVE
Practice Address - Street 2:VA DENTAL CLINIC
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2631
Practice Address - Country:US
Practice Address - Phone:860-667-6781
Practice Address - Fax:860-667-6827
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2009-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008786122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008786OtherDENTIST LICENSE
CT30033OtherCONTROLLED SUBSTANCE