Provider Demographics
NPI:1124043583
Name:NELSON, MARK W (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
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 1193
Mailing Address - Street 2:
Mailing Address - City:HETTINGER
Mailing Address - State:ND
Mailing Address - Zip Code:58639-1193
Mailing Address - Country:US
Mailing Address - Phone:701-567-4302
Mailing Address - Fax:701-567-4303
Practice Address - Street 1:204 HIGHWAY 12 E
Practice Address - Street 2:
Practice Address - City:HETTINGER
Practice Address - State:ND
Practice Address - Zip Code:58639-9687
Practice Address - Country:US
Practice Address - Phone:701-567-4302
Practice Address - Fax:701-567-4303
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND000812181OtherUCCI
ND1451441Medicaid
ND05072001OtherBC/BS
ND000812181OtherUCCI