Provider Demographics
NPI:1215501440
Name:LOPEZ, EDUARDO DOMINGO (DMD)
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:DOMINGO
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 1:4326 GEORGE WASHINGTON MEM HWY
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-2707
Mailing Address - Country:US
Mailing Address - Phone:757-969-1356
Mailing Address - Fax:
Practice Address - Street 1:4326 GEORGE WASHINGTON MEM HWY
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692-2707
Practice Address - Country:US
Practice Address - Phone:757-969-1356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014172371223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty