Provider Demographics
NPI:1861650277
Name:JUAN R LOPEZ DDS
Entity Type:Organization
Organization Name:JUAN R LOPEZ DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KYLA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-536-9647
Mailing Address - Street 1:6941 W GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5311
Mailing Address - Country:US
Mailing Address - Phone:580-536-9647
Mailing Address - Fax:580-536-4075
Practice Address - Street 1:6941 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5311
Practice Address - Country:US
Practice Address - Phone:580-536-9647
Practice Address - Fax:580-536-4075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5022122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty