Healthcare Provider Details

I. General information

NPI: 1124059472
Provider Name (Legal Business Name): JAIME RIVERA D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7482 PASEO DEL NORTE
EL PASO TX
79911-3200
US

IV. Provider business mailing address

7482 PASEO DEL NORTE
EL PASO TX
79911-3200
US

V. Phone/Fax

Practice location:
  • Phone: 915-585-7550
  • Fax: 915-585-7552
Mailing address:
  • Phone: 915-585-7550
  • Fax: 915-585-7552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22009
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22009
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: