Provider Demographics
NPI:1114060217
Name:RIVERA DAVILA, BRENDA (DMD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:RIVERA DAVILA
Suffix:
Gender:F
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 523
Mailing Address - Street 2:
Mailing Address - City:LUQUILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00773
Mailing Address - Country:US
Mailing Address - Phone:787-889-4390
Mailing Address - Fax:787-889-6554
Practice Address - Street 1:CONDOMINIO PLAYA AZUL IV
Practice Address - Street 2:LOCAL COMERCIAL G03
Practice Address - City:LUQUILLO
Practice Address - State:PR
Practice Address - Zip Code:00773
Practice Address - Country:US
Practice Address - Phone:787-889-4390
Practice Address - Fax:787-889-6554
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice