Provider Demographics
NPI:1124843271
Name:DE LA RIVA VARGAS, LYMARI JAMILETTE
Entity type:Individual
Prefix:
First Name:LYMARI
Middle Name:JAMILETTE
Last Name:DE LA RIVA VARGAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9902 JAMACHA BLVD SPC 23
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-8023
Mailing Address - Country:US
Mailing Address - Phone:619-463-0921
Mailing Address - Fax:
Practice Address - Street 1:1072 3RD AVE STE A
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2085
Practice Address - Country:US
Practice Address - Phone:619-425-5323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1073821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice