1124059472 NPI number — DR. JAIME RIVERA D.M.D

Table of content: DR. JAIME RIVERA D.M.D (NPI 1124059472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124059472 NPI number — DR. JAIME RIVERA D.M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
JAIME
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124059472
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6901 HELEN OF TROY BLDG D-1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79911-3043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-585-7550
Provider Business Mailing Address Fax Number:
915-585-7552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6901 HELEN OF TROY BLDG D-1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79911-3043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-585-7550
Provider Business Practice Location Address Fax Number:
915-585-7552
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  22009 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 22009 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 213495902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22009 . This is a "TEXAS LICENSE DENTIST" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00142477 . This is a "DPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 213495901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD3905 . This is a "NEW MEXICO DENTAL LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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