Provider Demographics
NPI:1053515114
Name:NELKE, MARK D (DMD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:D
Last Name:NELKE
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:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:BLAIRSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07825-0650
Mailing Address - Country:US
Mailing Address - Phone:908-362-8289
Mailing Address - Fax:908-362-8289
Practice Address - Street 1:196 RT 94
Practice Address - Street 2:
Practice Address - City:BLAIRSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07825-0650
Practice Address - Country:US
Practice Address - Phone:908-362-8289
Practice Address - Fax:908-362-8289
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD133921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD13392OtherLISCENCE