=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760908743
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINA NANETTE RIVERA RIVERA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2017
-----------------------------------------------------
Last Update Date | 11/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36 CALLE MARTINEZ STE 1
-----------------------------------------------------
City | JUNCOS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00777-3671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-918-2703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 ALTOS DE CIUDAD JARDIN
-----------------------------------------------------
City | GURABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00778-9101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-918-2703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3353
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 23007
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------