Provider Demographics
NPI:1174657787
Name:GLECKNER, MARK JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:GLECKNER
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 1:66 RIDGEDALE AVE
Mailing Address - Street 2:
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-2006
Mailing Address - Country:US
Mailing Address - Phone:973-377-1174
Mailing Address - Fax:973-377-4721
Practice Address - Street 1:66 RIDGEDALE AVE
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-2006
Practice Address - Country:US
Practice Address - Phone:973-377-1174
Practice Address - Fax:973-377-4721
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI199171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice