Provider Demographics
NPI:1457564841
Name:SMITH, DERRICK TRIGENZA (BSDH)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:TRIGENZA
Last Name:SMITH
Suffix:
Gender:M
Credentials:BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11383 BOONE WAY
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-796-9676
Mailing Address - Fax:
Practice Address - Street 1:23569 SUNNYMEAD RANCH PARKWAY
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557
Practice Address - Country:US
Practice Address - Phone:951-242-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19816124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist