Provider Demographics
NPI:1790902989
Name:RIVERA, REYNALDO DAVID (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:REYNALDO
Middle Name:DAVID
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 S GLENN DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-7944
Mailing Address - Country:US
Mailing Address - Phone:805-738-3287
Mailing Address - Fax:
Practice Address - Street 1:67 S GLENN DR
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-7944
Practice Address - Country:US
Practice Address - Phone:805-738-3287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019099122300000X, 1223S0112X
CADDS1060441223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist