Provider Demographics
NPI:1356544027
Name:NOLL, MARK J
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:NOLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 PARNELL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5836
Mailing Address - Country:US
Mailing Address - Phone:269-048-2838
Mailing Address - Fax:
Practice Address - Street 1:4504 PARNELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5836
Practice Address - Country:US
Practice Address - Phone:269-048-2838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010479A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice