Provider Demographics
NPI:1184860561
Name:NELSON, TYLER ELLIOTT (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:ELLIOTT
Last Name:NELSON
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 1:2801 WATERMAN BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-2987
Mailing Address - Country:US
Mailing Address - Phone:707-428-5427
Mailing Address - Fax:707-428-1922
Practice Address - Street 1:2801 WATERMAN BLVD STE 240
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-2987
Practice Address - Country:US
Practice Address - Phone:707-428-5427
Practice Address - Fax:707-428-1922
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56695122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist