Provider Demographics
NPI:1881031888
Name:CARLOS LOPEZ
Entity Type:Organization
Organization Name:CARLOS LOPEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:01152656-611-3656
Mailing Address - Street 1:PO BOX 12385
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79913-0385
Mailing Address - Country:US
Mailing Address - Phone:915-726-0929
Mailing Address - Fax:
Practice Address - Street 1:18 DE MARZO #2952
Practice Address - Street 2:
Practice Address - City:CIUDAD JUAREZ
Practice Address - State:CHIHUAHUA
Practice Address - Zip Code:32330
Practice Address - Country:MX
Practice Address - Phone:01152656-611-3656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ2932056122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty