Provider Demographics
NPI:1326872417
Name:RIVERVIEW ENDODONTICS LLC
Entity type:Organization
Organization Name:RIVERVIEW ENDODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:INGMAR
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-408-3636
Mailing Address - Street 1:27399 RIVERVIEW CENTER BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4311
Mailing Address - Country:US
Mailing Address - Phone:239-408-3636
Mailing Address - Fax:
Practice Address - Street 1:27399 RIVERVIEW CENTER BLVD STE 104
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4311
Practice Address - Country:US
Practice Address - Phone:239-408-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN24712OtherDENTAL LICENSE