Provider Demographics
NPI:1215344106
Name:RIVERA, CANDIDO (DDS)
Entity type:Individual
Prefix:DR
First Name:CANDIDO
Middle Name:
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 1:7117 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-1450
Mailing Address - Country:US
Mailing Address - Phone:262-942-7000
Mailing Address - Fax:
Practice Address - Street 1:2936 N NEENAH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4960
Practice Address - Country:US
Practice Address - Phone:773-369-6381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-13
Last Update Date:2014-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1000959-15122300000X
IL019029937122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist