Provider Demographics
NPI:1851196968
Name:RENAISSANCE DENTAL & SURGICAL ARTS, INC.
Entity type:Organization
Organization Name:RENAISSANCE DENTAL & SURGICAL ARTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GINO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:REYNOSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-294-7230
Mailing Address - Street 1:258 N 900 E
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5541
Mailing Address - Country:US
Mailing Address - Phone:951-294-7230
Mailing Address - Fax:
Practice Address - Street 1:3707 N CANYON RD STE 2A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4525
Practice Address - Country:US
Practice Address - Phone:951-294-7230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-14
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty