Provider Demographics
NPI:1649901976
Name:LOPEZ, JADE RASHIDA (DDS)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:RASHIDA
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 1:3610 SW 165TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4513
Mailing Address - Country:US
Mailing Address - Phone:954-662-4922
Mailing Address - Fax:
Practice Address - Street 1:24185 US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33859-7819
Practice Address - Country:US
Practice Address - Phone:863-676-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN27169122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program