Provider Demographics
NPI:1003591215
Name:RIVERA, JONATHON (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4240
Mailing Address - Country:US
Mailing Address - Phone:863-676-6021
Mailing Address - Fax:
Practice Address - Street 1:701 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4240
Practice Address - Country:US
Practice Address - Phone:863-676-6021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28159122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist