Provider Demographics
NPI:1114755816
Name:LOPEZ, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42031 CYPRESS PKWY UNIT 6
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33982-5138
Mailing Address - Country:US
Mailing Address - Phone:941-833-1639
Mailing Address - Fax:
Practice Address - Street 1:42031 CYPRESS PKWY UNIT 6
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33982-5138
Practice Address - Country:US
Practice Address - Phone:941-833-1639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN29428122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist