Provider Demographics
NPI:1801075775
Name:ROXANA LOPEZ, DDS,PA
Entity type:Organization
Organization Name:ROXANA LOPEZ, DDS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-566-8233
Mailing Address - Street 1:2512 N. CONWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-0409
Mailing Address - Country:US
Mailing Address - Phone:956-483-0499
Mailing Address - Fax:
Practice Address - Street 1:4406 SIERRA DR
Practice Address - Street 2:
Practice Address - City:PALMHURST
Practice Address - State:TX
Practice Address - Zip Code:78573-0409
Practice Address - Country:US
Practice Address - Phone:956-566-8233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX224731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1649315672Medicaid