Provider Demographics
NPI:1104805746
Name:RIVERA, ANGEL ERNESTO (DDS)
Entity type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:ERNESTO
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:#823 CALLE DUENDE URB SAN ANTONIO
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00728-1615
Mailing Address - Country:US
Mailing Address - Phone:787-899-7717
Mailing Address - Fax:
Practice Address - Street 1:#12 UNION ESQ SAN BLAS
Practice Address - Street 2:
Practice Address - City:LAJAS
Practice Address - State:PR
Practice Address - Zip Code:00667
Practice Address - Country:US
Practice Address - Phone:787-899-7717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice