Provider Demographics
NPI:1134593288
Name:LOPEZ HERNANDEZ, MARCELO MANUEL (DDS)
Entity type:Individual
Prefix:MR
First Name:MARCELO
Middle Name:MANUEL
Last Name:LOPEZ HERNANDEZ
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 1:4364 BONITA RD. #233
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1421
Mailing Address - Country:US
Mailing Address - Phone:011-526-6462
Mailing Address - Fax:
Practice Address - Street 1:BLVD. BELLAS ARTES #341-1
Practice Address - Street 2:COLONIA NUEVA TIJUANA
Practice Address - City:TIJUANA
Practice Address - State:CA
Practice Address - Zip Code:22435
Practice Address - Country:US
Practice Address - Phone:011-526-6462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ871239122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist