Healthcare Provider Details

I. General information

NPI: 1821095092
Provider Name (Legal Business Name): MITCHELL B RESNICK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 NEWTON ST SUITE 1
SOUTH HADLEY MA
01075-2010
US

IV. Provider business mailing address

488 NEWTON ST SUITE 1
SOUTH HADLEY MA
01075-2010
US

V. Phone/Fax

Practice location:
  • Phone: 413-538-9604
  • Fax: 413-534-3533
Mailing address:
  • Phone: 413-538-9604
  • Fax: 413-534-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 12187-1
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: