Provider Demographics
NPI:1871227579
Name:RIVAS, JESSICA MITCHUM (DMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MITCHUM
Last Name:RIVAS
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 1:2012 GREYSTEM CIR APT 308
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9333
Mailing Address - Country:US
Mailing Address - Phone:865-293-9918
Mailing Address - Fax:
Practice Address - Street 1:814 RADFORD BLVD BLDG 7000
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31704-1130
Practice Address - Country:US
Practice Address - Phone:229-639-7886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11925122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist