Provider Demographics
NPI:1891460515
Name:LOPEZ, DESTINY MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:MARIE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8360 W EXPRESSWAY 83
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-2071
Mailing Address - Country:US
Mailing Address - Phone:956-581-5265
Mailing Address - Fax:
Practice Address - Street 1:8360 W EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-2071
Practice Address - Country:US
Practice Address - Phone:956-581-5265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX377171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice