Provider Demographics
NPI:1538223979
Name:RIVERA, ELISA M (DMD)
Entity type:Individual
Prefix:DR
First Name:ELISA
Middle Name:M
Last Name:RIVERA
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 1:4F10 CALLE 204
Mailing Address - Street 2:COLINAS DE FAIRVIEW
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-8215
Mailing Address - Country:US
Mailing Address - Phone:787-746-6660
Mailing Address - Fax:787-743-5255
Practice Address - Street 1:190 CARR 1 STE 12
Practice Address - Street 2:BAIROA SHOPPING CENTER
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-1586
Practice Address - Country:US
Practice Address - Phone:787-746-6660
Practice Address - Fax:787-743-5255
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2736122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist