Healthcare Provider Details

I. General information

NPI: 1053515114
Provider Name (Legal Business Name): MARK D NELKE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 RT 94
BLAIRSTOWN NJ
07825-0650
US

IV. Provider business mailing address

PO BOX 650
BLAIRSTOWN NJ
07825-0650
US

V. Phone/Fax

Practice location:
  • Phone: 908-362-8289
  • Fax: 908-362-8289
Mailing address:
  • Phone: 908-362-8289
  • Fax: 908-362-8289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD13392
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: