Healthcare Provider Details

I. General information

NPI: 1679627632
Provider Name (Legal Business Name): IVELISSE M RIMA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 87TH STREET 2ND FLOOR
JACKSON HEIGHTS NY
11372
US

IV. Provider business mailing address

3715 87TH STREET 2ND FLOOR
JACKSON HEIGHTS NY
11372-7534
US

V. Phone/Fax

Practice location:
  • Phone: 718-476-9244
  • Fax: 718-651-3814
Mailing address:
  • Phone: 718-476-9244
  • Fax: 718-651-3814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number036939
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: