Provider Demographics
NPI:1679866354
Name:RIVERA VEGA, JOHANNA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:RIVERA VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GALERIAS PLAZA GUAYAMA SUITE #7
Mailing Address - Street 2:LOS VETERANOS AVENUE
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00784
Mailing Address - Country:US
Mailing Address - Phone:787-864-8649
Mailing Address - Fax:
Practice Address - Street 1:7 AVE LOS VETERANOS
Practice Address - Street 2:GALERIAS PLAZA GUAYAMA SUITE
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-864-8649
Practice Address - Fax:787-864-8649
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR29071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program