Provider Demographics
NPI:1013058346
Name:RIVERA, JOSE W (DDS)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:W
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 N PEPPER AVE
Mailing Address - Street 2:STE E
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-6716
Mailing Address - Country:US
Mailing Address - Phone:909-370-3313
Mailing Address - Fax:
Practice Address - Street 1:1130 N PEPPER AVE
Practice Address - Street 2:STE E
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-6716
Practice Address - Country:US
Practice Address - Phone:909-370-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA425991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice