1912316456 NPI number — RIVERS FAMILY DENTISTRY, PLLC

Table of content: (NPI 1912316456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912316456 NPI number — RIVERS FAMILY DENTISTRY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERS FAMILY DENTISTRY, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1912316456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709C VASSAR CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77840-2142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-925-0458
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 E VILLA MARIA RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BRYAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77801-3147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-779-6146
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RIVERS
Authorized Official First Name:
KRISTINA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
979-779-6146

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  23933 , 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: 1740411016 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com