Healthcare Provider Details

I. General information

NPI: 1164911053
Provider Name (Legal Business Name): RENEE ANTOINETTE SMITH DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 07/16/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MDG/SGDTN 101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

60 MDG/SGDTN 101 BODIN CIR
TRAVIS AFB CA
94535
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDDS102766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: