Healthcare Provider Details

I. General information

NPI: 1982695433
Provider Name (Legal Business Name): CORY M RESNICK MD, DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE. BOSTON CHILDREN'S HOSPITAL, DPT. OF PLASTIC & ORAL SURG
BOSTON MA
02171
US

IV. Provider business mailing address

300 LONGWOOD AVE. BOSTON CHILDREN'S HOSPITAL, DPT. OF PLASTIC & ORAL SURG
BOSTON MA
02171
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6082
  • Fax: 617-738-1657
Mailing address:
  • Phone: 617-355-6082
  • Fax: 617-738-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN21469
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number8458
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: