Provider Demographics
NPI:1396290912
Name:LOPEZ, PATRICIA MIREYA (DDS)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:MIREYA
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 1:5 CARDINAL ST
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-6259
Mailing Address - Country:US
Mailing Address - Phone:956-735-8818
Mailing Address - Fax:
Practice Address - Street 1:1205 E ALTON GLOOR BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-3831
Practice Address - Country:US
Practice Address - Phone:956-735-8818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX322081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice