Provider Demographics
NPI:1912316456
Name:RIVERS FAMILY DENTISTRY, PLLC
Entity Type:Organization
Organization Name:RIVERS FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-779-6146
Mailing Address - Street 1:709C VASSAR CT
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-2142
Mailing Address - Country:US
Mailing Address - Phone:817-925-0458
Mailing Address - Fax:
Practice Address - Street 1:110 E VILLA MARIA RD
Practice Address - Street 2:SUITE A
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1740411016Medicaid