Basic Information
| Provider Information | |||||||||
| NPI: | 1336227743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | GIANIRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MALDANADO | ||||||||
| OtherFirstName: | GIANIRA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.D.S. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6601 S RURAL RD | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852833747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804560821 | ||||||||
| FaxNumber: | 4807566536 | ||||||||
| Practice Location | |||||||||
| Address1: | 5270 W BASELINE RD | ||||||||
| Address2: | #130 | ||||||||
| City: | LAVEEN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853396959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022378182 | ||||||||
| FaxNumber: | 4807566536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 06/01/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901018076 | MI | N | Dental Providers | Dentist | 122300000X | D7464 | AZ | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 4382600 | 05 | MI | MEDICAID | D802165 | 01 | MI | BCBS | OTHER |