Provider Demographics
NPI:1154619088
Name:LOPEZ, SERGIO ENRIQUE (DDS)
Entity type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:ENRIQUE
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BOB BULLOCK LOOP
Mailing Address - Street 2:APT. 8101
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043-4265
Mailing Address - Country:US
Mailing Address - Phone:956-212-3662
Mailing Address - Fax:
Practice Address - Street 1:1507 S MCCOLL RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78541-4265
Practice Address - Country:US
Practice Address - Phone:956-720-4345
Practice Address - Fax:956-720-4329
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27129122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX295598107Medicaid