Healthcare Provider Details

I. General information

NPI: 1386837805
Provider Name (Legal Business Name): LLISENIA E. RIVERA D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 GRAND CONCOURSE
BRONX NY
10457-5221
US

IV. Provider business mailing address

86 LONGVIEW AVE
HACKENSACK NJ
07601-1807
US

V. Phone/Fax

Practice location:
  • Phone: 718-583-6347
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number053658
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: