Provider Demographics
NPI:1679807069
Name:REYES, RENATO DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:RENATO
Middle Name:DAVID
Last Name:REYES
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 1:1625 SWEETWATER ROAD
Mailing Address - Street 2:SUITE G1
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950
Mailing Address - Country:US
Mailing Address - Phone:619-336-1588
Mailing Address - Fax:
Practice Address - Street 1:1625 SWEETWATER ROAD
Practice Address - Street 2:SUITE G1
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950
Practice Address - Country:US
Practice Address - Phone:619-336-1588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA407161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice