Provider Demographics
NPI:1770180242
Name:SMITH, AIREANA MARIE
Entity Type:Individual
Prefix:MRS
First Name:AIREANA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AIREANA
Other - Middle Name:MARIE
Other - Last Name:GAMBOA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:44642 LEE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-1855
Mailing Address - Country:US
Mailing Address - Phone:760-567-5824
Mailing Address - Fax:
Practice Address - Street 1:11092 ANDERSON STREER
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-0001
Practice Address - Country:US
Practice Address - Phone:909-558-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13065124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist