Provider Demographics
NPI:1265412852
Name:RESNICK, JERROLD B (DMD)
Entity type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:B
Last Name:RESNICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1329
Mailing Address - Country:US
Mailing Address - Phone:727-347-6450
Mailing Address - Fax:727-347-7906
Practice Address - Street 1:6450 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1329
Practice Address - Country:US
Practice Address - Phone:727-347-6450
Practice Address - Fax:727-347-7906
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN75841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice