Provider Demographics
NPI:1366586638
Name:DE JESUS RIVERA, ZULLY RUBI (DDS)
Entity type:Individual
Prefix:MRS
First Name:ZULLY
Middle Name:RUBI
Last Name:DE JESUS RIVERA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 AVE. HOSTOS EDIFICIO POLICLINICO BELLA VISTA
Mailing Address - Street 2:STE. 203
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680
Mailing Address - Country:US
Mailing Address - Phone:787-636-3300
Mailing Address - Fax:787-833-5574
Practice Address - Street 1:770 AVE. HOSTOS EDIFICIO POLICLINICO BELLA VISTA
Practice Address - Street 2:STE. 203
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-636-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2023-10-26
Deactivation Date:2021-10-08
Deactivation Code:
Reactivation Date:2021-10-26
Provider Licenses
StateLicense IDTaxonomies
PR31831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3183OtherPUERTO RICO HEALTH DEPARTMENT
PR039050901Medicaid
NY9176692OtherDORAL
NY02491523Medicaid