Provider Demographics
NPI:1700398021
Name:RIVERA, JONATHAN (N5)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:N5
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 SAINT MIHIEL ST
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-1654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2605 SAINT MIHIEL ST
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-1654
Practice Address - Country:US
Practice Address - Phone:615-663-2003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126900000XDental ProvidersDental Laboratory Technician