Healthcare Provider Details

I. General information

NPI: 1578559423
Provider Name (Legal Business Name): JUAN R RIVERA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDIF LA PALMA SUITE 3A
MAYAGUEZ PR
00680-4861
US

IV. Provider business mailing address

EDIF LA PALMA SUITE 3A
MAYAGUEZ PR
00680-4861
US

V. Phone/Fax

Practice location:
  • Phone: 787-834-1525
  • Fax: 787-986-7011
Mailing address:
  • Phone: 787-834-1525
  • Fax: 787-831-6005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1475
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: