Provider Demographics
NPI:1154314219
Name:RENALDO, MICHAEL A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:RENALDO
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 1:1521 8TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-1893
Mailing Address - Country:US
Mailing Address - Phone:610-865-8077
Mailing Address - Fax:610-865-8112
Practice Address - Street 1:1521 8TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-1893
Practice Address - Country:US
Practice Address - Phone:610-865-8077
Practice Address - Fax:610-865-8112
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019414L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01412301OtherCAPITAL BLUE CROSS
PA182033OtherUS HEALTHCARE
PADS019414LOtherDENTAL LICENSE NUMBER
PA232702929OtherFEDERAL TAX ID #
PA028552OtherPA BLUE SHIELD
PA028552OtherPA BLUE SHIELD
PA028552Medicare PIN
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