Provider Demographics
NPI:1124745740
Name:JUAN GUILLERMO LOPEZ DMD DDS PA
Entity type:Organization
Organization Name:JUAN GUILLERMO LOPEZ DMD DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:GUILLERMO
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PA
Authorized Official - Phone:239-768-1011
Mailing Address - Street 1:13300 S CLEVELAND AVE STE 46
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3883
Mailing Address - Country:US
Mailing Address - Phone:239-768-1011
Mailing Address - Fax:239-768-9311
Practice Address - Street 1:13300 S CLEVELAND AVE STE 46
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3883
Practice Address - Country:US
Practice Address - Phone:239-768-1011
Practice Address - Fax:239-768-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN17696OtherDENTAL LICENSE
FL1447281720OtherNPI 1