Healthcare Provider Details

I. General information

NPI: 1437379997
Provider Name (Legal Business Name): DR. MARK P WELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 E TREMONT AVE
BRONX NY
10460-4305
US

IV. Provider business mailing address

949 E TREMONT AVE
BRONX NY
10460-4305
US

V. Phone/Fax

Practice location:
  • Phone: 718-589-8604
  • Fax: 718-617-3824
Mailing address:
  • Phone: 718-589-8604
  • Fax: 718-617-3824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number029097
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: