Provider Demographics
NPI:1073175410
Name:SMITH, REAGAN AUSTIN CARL (DDS)
Entity Type:Individual
Prefix:
First Name:REAGAN
Middle Name:AUSTIN CARL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19702 BELLA LOMA APT 8002
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78256-0008
Mailing Address - Country:US
Mailing Address - Phone:512-289-5597
Mailing Address - Fax:
Practice Address - Street 1:13205 GEORGE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-3018
Practice Address - Country:US
Practice Address - Phone:210-492-0205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-06
Last Update Date:2019-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352921223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice