Provider Demographics
NPI:1114215902
Name:RIVERA, SAMUEL RAUL (DDS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RAUL
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33978 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-6934
Mailing Address - Country:US
Mailing Address - Phone:714-650-3589
Mailing Address - Fax:
Practice Address - Street 1:3915 W DAVIS ST STE 160
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1879
Practice Address - Country:US
Practice Address - Phone:936-760-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA604931223G0001X
TX316851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice