Provider Demographics
NPI:1518017482
Name:RESNICK, MARVIN JAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:JAY
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 1:2503 LOWRY AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-1010
Mailing Address - Country:US
Mailing Address - Phone:612-522-1188
Mailing Address - Fax:612-522-8422
Practice Address - Street 1:2503 LOWRY AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-1010
Practice Address - Country:US
Practice Address - Phone:612-522-1188
Practice Address - Fax:612-522-8422
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN75121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7512OtherDENTAL LIC. NM.
MN6026472OtherSTATE TAX NUMBER