Provider Demographics
NPI:1891030292
Name:RIVERA, NICOLE MELISSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MELISSA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VIA CORDILLERA F26
Mailing Address - Street 2:LA VISTA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924-8231
Mailing Address - Country:US
Mailing Address - Phone:787-505-2831
Mailing Address - Fax:
Practice Address - Street 1:VIA CORDILLERA F26
Practice Address - Street 2:LA VISTA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-8231
Practice Address - Country:US
Practice Address - Phone:787-505-2831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2014-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR003112122300000X
390200000X
VA04014143701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program