Provider Demographics
NPI:1982195194
Name:RESNIK, TARA MARIE (DMD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:RESNIK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 STONEFIELD LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5337
Mailing Address - Country:US
Mailing Address - Phone:386-742-4359
Mailing Address - Fax:
Practice Address - Street 1:229 WHEELHOUSE LN STE 1241
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3665
Practice Address - Country:US
Practice Address - Phone:954-701-0871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0419461223G0001X
390200000X
FLDN234021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035592260001Medicaid