Provider Demographics
NPI:1609896752
Name:LOPEZ, JUAN CARLOS (DMD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 NW 16TH ST
Mailing Address - Street 2:DENTAL SERVICE (160), VA MEDICAL CENTER
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-1624
Mailing Address - Country:US
Mailing Address - Phone:305-575-3146
Mailing Address - Fax:305-575-3373
Practice Address - Street 1:1201 NW 16TH ST
Practice Address - Street 2:DENTAL SERVICE (160), VA MEDICAL CENTER
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1624
Practice Address - Country:US
Practice Address - Phone:305-575-3146
Practice Address - Fax:305-575-3373
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN155761223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics