Healthcare Provider Details

I. General information

NPI: 1952303687
Provider Name (Legal Business Name): JOSE ANGEL RIVERA-GAUTIER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5681 FAIRMONT PKWY STE B
PASADENA TX
77505-3903
US

IV. Provider business mailing address

2536 AMHERST ST STE A
HOUSTON TX
77005-3207
US

V. Phone/Fax

Practice location:
  • Phone: 281-998-8800
  • Fax:
Mailing address:
  • Phone: 713-490-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2321
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number27318
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: