Provider Demographics
NPI:1003982406
Name:NELSON, JON GREGORIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:GREGORIE
Last Name:NELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 23RD AVE E
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3707
Mailing Address - Country:US
Mailing Address - Phone:715-398-3239
Mailing Address - Fax:715-398-5799
Practice Address - Street 1:418 23RD AVE E
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3707
Practice Address - Country:US
Practice Address - Phone:715-398-3239
Practice Address - Fax:715-398-5799
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI 38981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33679400Medicaid
WI437434OtherUNITED CONCORDIA
WIWI 3898OtherLICENSE
MN06508NEOtherBCBS MN IDENTIFIER