Basic Information
| Provider Information | |||||||||
| NPI: | 1770990285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | GUADALUPE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 808 N MISSION PKWY | ||||||||
| Address2: | |||||||||
| City: | CASA GRANDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851948412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204263639 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2016 W 16TH ST | ||||||||
| Address2: | |||||||||
| City: | SAFFORD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855464026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284281500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2014 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D009003 | AZ | N | Dental Providers | Dentist | 1223G0001X | D009003 | AZ | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 949413 | 05 | AZ | MEDICAID |