Provider Demographics
NPI:1285244400
Name:RIERA DE JESUS, ALEJANDRA MICHELLE (DMD)
Entity type:Individual
Prefix:
First Name:ALEJANDRA
Middle Name:MICHELLE
Last Name:RIERA DE JESUS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 JAMESTOWN LN APT 9306
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-6185
Mailing Address - Country:US
Mailing Address - Phone:787-649-8544
Mailing Address - Fax:
Practice Address - Street 1:10670 SW TRADITION PKWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2862
Practice Address - Country:US
Practice Address - Phone:772-345-8332
Practice Address - Fax:772-345-8337
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL252861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice