Provider Demographics
NPI:1285204826
Name:RIVACOBA, GUILLERMO (DDS)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:RIVACOBA
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 1:721 AUSTIN AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76701-2056
Mailing Address - Country:US
Mailing Address - Phone:210-371-4908
Mailing Address - Fax:
Practice Address - Street 1:113 BURNETT CT
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-3100
Practice Address - Country:US
Practice Address - Phone:254-776-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-27
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX373851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice