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General NPI Number Information
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NPI Number | 1851196968
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Entity Type | Organization
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Legal Business Name | RENAISSANCE DENTAL & SURGICAL ARTS, INC.
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Dates
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Enumeration Date | 02/14/2025
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Last Update Date | 02/14/2025
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Provider Practice Location Address
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Address Line | 3707 N CANYON RD STE 2A
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City | PROVO
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State | UT
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Zip | 84604-4525
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Country | US
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Telephone | 951-294-7230
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Fax |
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Provider Business Mailing Address
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Address Line | 258 N 900 E
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City | SALEM
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State | UT
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Zip | 84653-5541
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Country | US
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Telephone | 951-294-7230
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Fax |
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Authorized Official
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Title or Position | OWNER/PERIODONTIST
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Name | DR. GINO ANTONIO REYNOSO
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Credential | DDS
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Telephone | 951-294-7230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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