Provider Demographics
NPI:1174523799
Name:REZNIK, MICHAEL LOUIS (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LOUIS
Last Name:REZNIK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3831 E 52ND ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-4762
Mailing Address - Country:US
Mailing Address - Phone:432-333-7105
Mailing Address - Fax:432-333-9490
Practice Address - Street 1:3831 E 52ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-4762
Practice Address - Country:US
Practice Address - Phone:432-333-7105
Practice Address - Fax:432-333-9490
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU14859Medicare UPIN