Provider Demographics
NPI:1073502860
Name:RIVERA, JUAN (DMD)
Entity Type:Individual
Prefix:
First Name:JUAN
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:PO BOX 1087
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-1087
Mailing Address - Country:US
Mailing Address - Phone:787-863-2549
Mailing Address - Fax:787-852-4685
Practice Address - Street 1:53 CALLE GARRIDO MORALES E
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-4665
Practice Address - Country:US
Practice Address - Phone:787-863-2549
Practice Address - Fax:787-852-4685
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR41009Medicare ID - Type UnspecifiedPROVEEDOR