Provider Demographics
NPI:1205960564
Name:LOPEZ-ROSARIO, JUAN E (DMD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:E
Last Name:LOPEZ-ROSARIO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JUAN
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:29 CROSSROADS DRIVE
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069
Mailing Address - Country:US
Mailing Address - Phone:315-592-2400
Mailing Address - Fax:315-592-2400
Practice Address - Street 1:29 CROSSROADS DRIVE
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069
Practice Address - Country:US
Practice Address - Phone:315-592-2400
Practice Address - Fax:315-592-2400
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052831-1122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist