Provider Demographics
NPI:1114153632
Name:RIVERA, VICKI ANNE (DMD)
Entity Type:Individual
Prefix:MISS
First Name:VICKI
Middle Name:ANNE
Last Name:RIVERA
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 1:22 PEOPLES PL
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01832-3654
Mailing Address - Country:US
Mailing Address - Phone:916-397-7860
Mailing Address - Fax:
Practice Address - Street 1:287 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-1010
Practice Address - Country:US
Practice Address - Phone:617-783-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855127122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist