Provider Demographics
NPI:1780144501
Name:SMITH, TRISTEN DAVID
Entity type:Individual
Prefix:
First Name:TRISTEN
Middle Name:DAVID
Last Name:SMITH
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 1:7511 APACHE TRL
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-3283
Mailing Address - Country:US
Mailing Address - Phone:760-464-3591
Mailing Address - Fax:
Practice Address - Street 1:58417 TWENTYNINE PALMS HIGHWAY
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7310
Practice Address - Country:US
Practice Address - Phone:760-853-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X, 175T00000X
CA171M00000X, 390200000X
CAMPSS-XRYJKD175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist