Provider Demographics
NPI:1528266160
Name:RIVERA, GRACE C (DDS)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:C
Last Name:RIVERA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:CABILDO-RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2508 JOHNS WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8368
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA483641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB48364-01OtherHEALTHY FAMILIES
CA1332285OtherUNITED CONCORDIA
CAG93378-01OtherDENTICAL