Provider Demographics
NPI:1962408104
Name:RIVERA, JORGE LUIS (DMD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CALLE SANTIAGO VEVE
Mailing Address - Street 2:
Mailing Address - City:JUANA DIAZ
Mailing Address - State:PR
Mailing Address - Zip Code:00795-1653
Mailing Address - Country:US
Mailing Address - Phone:787-837-8667
Mailing Address - Fax:787-837-9679
Practice Address - Street 1:4 CALLE SANTIAGO VEVE
Practice Address - Street 2:
Practice Address - City:JUANA DIAZ
Practice Address - State:PR
Practice Address - Zip Code:00795-1653
Practice Address - Country:US
Practice Address - Phone:787-837-8667
Practice Address - Fax:787-837-9679
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRD21311223G0001X
PR021311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice