Healthcare Provider Details

I. General information

NPI: 1154314219
Provider Name (Legal Business Name): MICHAEL A RENALDO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 8TH AVE STE 101
BETHLEHEM PA
18018-1893
US

IV. Provider business mailing address

1521 8TH AVE STE 101
BETHLEHEM PA
18018-1893
US

V. Phone/Fax

Practice location:
  • Phone: 610-865-8077
  • Fax: 610-865-8112
Mailing address:
  • Phone: 610-865-8077
  • Fax: 610-865-8112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS019414L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: