=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801943097
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AIDA I RIVERA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 09/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48 CALLE RAFAEL LASA
-----------------------------------------------------
City | AGUAS BUENAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00703-3321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-732-3577
-----------------------------------------------------
Fax | 787-732-3577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1212
-----------------------------------------------------
City | AGUAS BUENAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00703-1212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-732-3577
-----------------------------------------------------
Fax | 787-732-3577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1957
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------