Provider Demographics
NPI:1568522266
Name:RIVERA, MELISSA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 N RAUL LONGORIA RD/PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-0186
Mailing Address - Country:US
Mailing Address - Phone:956-787-9866
Mailing Address - Fax:956-787-8588
Practice Address - Street 1:4500 N RAUL LONGORIA RD
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-0186
Practice Address - Country:US
Practice Address - Phone:956-787-9866
Practice Address - Fax:956-787-8588
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21320122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB21320OtherCHIPS