Provider Demographics
NPI:1033320833
Name:NELSON, ETHAN BLAKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:BLAKE
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:PO BOX 646
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-0646
Mailing Address - Country:US
Mailing Address - Phone:252-482-5131
Mailing Address - Fax:
Practice Address - Street 1:103 MARK DR
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1704
Practice Address - Country:US
Practice Address - Phone:252-482-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC83931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice