Provider Demographics
NPI:1871671016
Name:WALTKE, CARL PAUL (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:PAUL
Last Name:WALTKE
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 1:180 OLD TAPPAN RD
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7052
Mailing Address - Country:US
Mailing Address - Phone:201-767-4001
Mailing Address - Fax:201-767-4632
Practice Address - Street 1:180 OLD TAPPAN RD
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-7052
Practice Address - Country:US
Practice Address - Phone:201-767-4001
Practice Address - Fax:201-767-4632
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ164381223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ200025OtherAETNA US HEALTH CARE
NJWA610091Medicare ID - Type Unspecified
NJ200025OtherAETNA US HEALTH CARE