Provider Demographics
NPI:1255408449
Name:LOPEZ, GLORIANA M (DDS)
Entity type:Individual
Prefix:
First Name:GLORIANA
Middle Name:M
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 1:224 29TH STREET OCEAN
Mailing Address - Street 2:
Mailing Address - City:MARATHON
Mailing Address - State:FL
Mailing Address - Zip Code:33050-2218
Mailing Address - Country:US
Mailing Address - Phone:512-970-4919
Mailing Address - Fax:
Practice Address - Street 1:2855 OVERSEAS HWY
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:FL
Practice Address - Zip Code:33050-2239
Practice Address - Country:US
Practice Address - Phone:305-743-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174311223G0001X
FLDN96641223G0001X
GADN0097541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice