Provider Demographics
NPI:1215953112
Name:GRACE CABILDO-RIVERA A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:GRACE CABILDO-RIVERA A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:CABILDO
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:925-755-4040
Mailing Address - Street 1:4847 LONE TREE WAY STE B
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8612
Mailing Address - Country:US
Mailing Address - Phone:925-755-4040
Mailing Address - Fax:925-755-4041
Practice Address - Street 1:4847 LONE TREE WAY STE B
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8612
Practice Address - Country:US
Practice Address - Phone:925-755-4040
Practice Address - Fax:925-755-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA483641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA341996792OtherOLD TAX I.D NUMBER
CAB48364-01OtherHEALTHY FAMILIES PROVIDER
CA1332285OtherUNITED CONCORDIA PROVIDER
CAG9337801Medicaid