MEDICARE: ILEANA RIVERA DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	1869	PR

General Provider Information

NPI Number	:	1992791347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILEANA RIVERA DMD

Provider Business Mailing Address
First Line	:	P3 CALLE ESTRELLA DEL MAR
Second Line	:	DORADO DEL MAR
City	:	DORADO
State	:	PR
Zip	:	00646-2155
Country	:	US
Telephone Number	:	787-796-2011
Fax Number	:	787-758-3858

Provider Business Practice Location Address
First Line	:	380 CALLE CESAR GONZALEZ
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00918-2113
Country	:	US
Telephone Number	:	787-758-3858
Fax Number	:	787-758-3858

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	07/08/2007

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