Provider Demographics
NPI:1477528511
Name:RIVERA, LOUIS RAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
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 1:4824 MCMAHON BLVD NW
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5412
Mailing Address - Country:US
Mailing Address - Phone:505-890-1911
Mailing Address - Fax:505-890-5014
Practice Address - Street 1:4824 MCMAHON BLVD NW
Practice Address - Street 2:SUITE 105
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5412
Practice Address - Country:US
Practice Address - Phone:505-890-1911
Practice Address - Fax:505-890-5014
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD15371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice