Provider Demographics
NPI:1407314974
Name:RIVERA HERNANDEZ, RAUL E JR
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:E
Last Name:RIVERA HERNANDEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4785 COVE ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-8956
Mailing Address - Country:US
Mailing Address - Phone:951-357-3904
Mailing Address - Fax:
Practice Address - Street 1:3027 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-3617
Practice Address - Country:US
Practice Address - Phone:951-330-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA917841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice