Basic Information
Provider Information
NPI: 1710178314
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LOPEZ
FirstName: RODOLFO
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 961629
Address2:  
City: EL PASO
State: TX
PostalCode: 79996
CountryCode: US
TelephoneNumber: 9155911709
FaxNumber: 9155911709
Practice Location
Address1: MAUNEL GOMEZ MORIN #74974
Address2:  
City: CD JUAREZ
State: CHIH
PostalCode: 32310
CountryCode: MX
TelephoneNumber: 237067
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/08/2007
LastUpdateDate: 08/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X2754706TXY Dental ProvidersDentist 

No ID Information.


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