Provider Demographics
NPI:1538550462
Name:LOPEZ, MARIA ESTHER
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:ESTHER
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14411 NW 83RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5714
Mailing Address - Country:US
Mailing Address - Phone:305-431-2441
Mailing Address - Fax:
Practice Address - Street 1:11401 PINES BLVD STE 220
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-4104
Practice Address - Country:US
Practice Address - Phone:954-432-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21166122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016679500Medicaid