Provider Demographics
NPI:1164436804
Name:THE NELSON DENTAL PRACTICE PC
Entity Type:Organization
Organization Name:THE NELSON DENTAL PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HOWELL
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-361-2141
Mailing Address - Street 1:9216 CENTREVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5131
Mailing Address - Country:US
Mailing Address - Phone:703-361-2141
Mailing Address - Fax:703-393-7391
Practice Address - Street 1:9216 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5131
Practice Address - Country:US
Practice Address - Phone:703-361-2141
Practice Address - Fax:703-393-7391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
VA0401007907332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7497680001Medicare NSC