MEDICARE: DR. JACLYN F RIVERA D.M.D

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	1223E0200X	Endodontics	DN21806	FL
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1871930727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACLYN F RIVERA D.M.D

Provider Business Mailing Address
First Line	:	13246 N DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-2408
Country	:	US
Telephone Number	:	813-926-6776
Fax Number	:

Provider Business Practice Location Address
First Line	:	13246 N DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-2408
Country	:	US
Telephone Number	:	813-926-6776
Fax Number	:

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

Provider Enumeration Date	:	06/03/2013
Last Update Date	:	05/18/2016

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