Provider Demographics
NPI:1639783053
Name:SMITH, ERICKA RENEE (DA 3160)
Entity Type:Individual
Prefix:MRS
First Name:ERICKA
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DA 3160
Other - Prefix:
Other - First Name:ERICKA
Other - Middle Name:RENEE
Other - Last Name:DENNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:280 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HOLLOMAN AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88330-8273
Mailing Address - Country:US
Mailing Address - Phone:575-572-3742
Mailing Address - Fax:575-572-7634
Practice Address - Street 1:280 1ST ST
Practice Address - Street 2:
Practice Address - City:HOLLOMAN AFB
Practice Address - State:NM
Practice Address - Zip Code:88330-8273
Practice Address - Country:US
Practice Address - Phone:575-572-3742
Practice Address - Fax:575-572-7634
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDA3160126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant