MEDICARE: MRS. IVELISSE M RIMA DDS

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	122300000X	Dentist	036939	NY

General Provider Information

NPI Number	:	1679627632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IVELISSE M RIMA DDS

Provider Business Mailing Address
First Line	:	3715 87TH STREET
Second Line	:	2ND FLOOR
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-7534
Country	:	US
Telephone Number	:	718-476-9244
Fax Number	:	718-651-3814

Provider Business Practice Location Address
First Line	:	3715 87TH STREET
Second Line	:	2ND FLOOR
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372
Country	:	US
Telephone Number	:	718-476-9244
Fax Number	:	718-651-3814

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

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/08/2007

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