Provider Demographics
NPI:1952380131
Name:LOPEZ, KATIE (RDH)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2279 MOUNT VERNON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1007
Mailing Address - Country:US
Mailing Address - Phone:860-426-0467
Mailing Address - Fax:860-426-2509
Practice Address - Street 1:2279 MOUNT VERNON RD
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1007
Practice Address - Country:US
Practice Address - Phone:860-426-0467
Practice Address - Fax:860-426-2509
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003839124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236354Medicaid