Provider Demographics
NPI:1134739873
Name:LOPEZ, ANALYSSA DOMINGUEZ
Entity type:Individual
Prefix:
First Name:ANALYSSA
Middle Name:DOMINGUEZ
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ANALYSSA
Other - Middle Name:DOMINGUEZ
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3531 MENDOCINO PARK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-2456
Mailing Address - Country:US
Mailing Address - Phone:210-248-4523
Mailing Address - Fax:
Practice Address - Street 1:244 FM 306 STE 118
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-5487
Practice Address - Country:US
Practice Address - Phone:830-201-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX364071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice