Provider Demographics
NPI:1366500969
Name:RIVERA, EMILIO ENRIQUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:EMILIO
Middle Name:ENRIQUE
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 1:8182 LARK BROWN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6428
Mailing Address - Country:US
Mailing Address - Phone:410-799-2692
Mailing Address - Fax:410-799-3931
Practice Address - Street 1:8182 LARK BROWN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6428
Practice Address - Country:US
Practice Address - Phone:410-799-2692
Practice Address - Fax:410-799-3931
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD79021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice