=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124061007
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT RESNICK D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 MAIN ST SUITE 2C
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06614-4946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-377-8480
-----------------------------------------------------
Fax | 203-377-3058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 COTTON TAIL TRL
-----------------------------------------------------
City | TRUMBULL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06611-1507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-261-9595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5383
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------