Provider Demographics
NPI:1871930727
Name:RIVERA, JACLYN F (DMD)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:F
Last Name:RIVERA
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 1:13246 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2408
Mailing Address - Country:US
Mailing Address - Phone:813-926-6776
Mailing Address - Fax:
Practice Address - Street 1:13246 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2408
Practice Address - Country:US
Practice Address - Phone:813-926-6776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN218061223E0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program