Provider Demographics
NPI:1891795761
Name:WALTZER, MARK LEWIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEWIS
Last Name:WALTZER
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 1:1930 MARLTON PIKE E
Mailing Address - Street 2:SUITE X-114
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-4214
Mailing Address - Country:US
Mailing Address - Phone:856-429-6412
Mailing Address - Fax:856-429-6341
Practice Address - Street 1:1930 MARLTON PIKE E
Practice Address - Street 2:SUITE X-114
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-4214
Practice Address - Country:US
Practice Address - Phone:856-429-6412
Practice Address - Fax:856-429-6341
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI 013809001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice