MEDICARE: JESSICA RIVAS-PLATA D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	17759	FL

General Provider Information

NPI Number	:	1285751503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA RIVAS-PLATA D.D.S.

Provider Business Mailing Address
First Line	:	9981 NW 9TH CT
Second Line	:
City	:	PLANTATION
State	:	FL
Zip	:	33324-1159
Country	:	US
Telephone Number	:	954-915-6823
Fax Number	:

Provider Business Practice Location Address
First Line	:	2609 W OAKLAND PARK BLVD
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33311-1355
Country	:	US
Telephone Number	:	954-485-1170
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	07/08/2007

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