Provider Demographics
NPI:1982695433
Name:RESNICK, CORY M (MD, DMD)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:M
Last Name:RESNICK
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE.
Mailing Address - Street 2:BOSTON CHILDREN'S HOSPITAL, DPT. OF PLASTIC & ORAL SURG
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02171
Mailing Address - Country:US
Mailing Address - Phone:617-355-6082
Mailing Address - Fax:617-738-1657
Practice Address - Street 1:300 LONGWOOD AVE.
Practice Address - Street 2:BOSTON CHILDREN'S HOSPITAL, DPT. OF PLASTIC & ORAL SURG
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02171
Practice Address - Country:US
Practice Address - Phone:617-355-6082
Practice Address - Fax:617-738-1657
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN214691223S0112X
MA8458204E00000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ225793ABKMedicare PIN