Provider Demographics
NPI:1740411016
Name:RIVERS, KRISTINA (DDS)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:RIVERS
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 1:110 E VILLA MARIA RD
Mailing Address - Street 2:STE A
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77801-3147
Mailing Address - Country:US
Mailing Address - Phone:979-779-6146
Mailing Address - Fax:979-779-6250
Practice Address - Street 1:110 E VILLA MARIA RD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77801-3147
Practice Address - Country:US
Practice Address - Phone:979-779-6146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2038713-02Medicaid