Provider Demographics
NPI:1255549747
Name:ANTONIO, RENATO G
Entity type:Individual
Prefix:
First Name:RENATO
Middle Name:G
Last Name:ANTONIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 WHEATON WAY
Mailing Address - Street 2:#206
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3440
Mailing Address - Country:US
Mailing Address - Phone:360-627-7751
Mailing Address - Fax:
Practice Address - Street 1:2817 WHEATON WAY
Practice Address - Street 2:#206
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3440
Practice Address - Country:US
Practice Address - Phone:360-627-7751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000366122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist