Provider Demographics
NPI:1316910201
Name:SCHULTE, MARK J (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:SCHULTE
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 1:4515 CHURCHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1109
Mailing Address - Country:US
Mailing Address - Phone:502-361-0637
Mailing Address - Fax:502-361-0636
Practice Address - Street 1:4515 CHURCHMAN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1109
Practice Address - Country:US
Practice Address - Phone:502-361-0637
Practice Address - Fax:502-361-0636
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60048121Medicaid
KY60048121Medicaid