Healthcare Provider Details

I. General information

NPI: 1124265988
Provider Name (Legal Business Name): EVA ELENA RIVERA RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 02/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 PRAIRIE DUNES DR
CORONA CA
92883-0686
US

IV. Provider business mailing address

4106 PRAIRIE DUNES DR
CORONA CA
92883-0686
US

V. Phone/Fax

Practice location:
  • Phone: 951-549-8709
  • Fax:
Mailing address:
  • Phone: 951-549-8709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number71314
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: