Provider Demographics
NPI:1265441125
Name:LOPEZ, SERGIO MAX (DDS)
Entity type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:MAX
Last Name:LOPEZ
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 1:3102 W WATERS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2882
Mailing Address - Country:US
Mailing Address - Phone:813-374-2441
Mailing Address - Fax:813-513-2925
Practice Address - Street 1:3102 W WATERS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2882
Practice Address - Country:US
Practice Address - Phone:813-374-2441
Practice Address - Fax:813-513-2925
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL182291223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013389200Medicaid
FL007861100Medicaid