Healthcare Provider Details

I. General information

NPI: 1528754546
Provider Name (Legal Business Name): RIVERA & ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 N TRYON ST
CHARLOTTE NC
28213-7076
US

IV. Provider business mailing address

3340 ROBINWOOD RD STE 100-406
GASTONIA NC
28054-6689
US

V. Phone/Fax

Practice location:
  • Phone: 704-981-2110
  • Fax:
Mailing address:
  • Phone: 719-406-2921
  • Fax: 704-398-7373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN PATRICK ROOT
Title or Position: PRESIDENT OF BUSINESS OPERATIONS
Credential:
Phone: 719-406-2921