Provider Demographics
NPI:1730594540
Name:ACEVEDO RIVERA, GRISEL (DMD)
Entity type:Individual
Prefix:
First Name:GRISEL
Middle Name:
Last Name:ACEVEDO 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 1:6725 SPENCER HWY # 19
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-1755
Mailing Address - Country:US
Mailing Address - Phone:832-821-8400
Mailing Address - Fax:
Practice Address - Street 1:6725 SPENCER HWY # 19
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-1755
Practice Address - Country:US
Practice Address - Phone:832-821-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX31424122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program