Provider Demographics
NPI:1225015977
Name:NELSON, JACY CRAIG (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACY
Middle Name:CRAIG
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 1:19221 108TH AVE SE STE 2
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-7369
Mailing Address - Country:US
Mailing Address - Phone:253-852-0206
Mailing Address - Fax:253-852-5361
Practice Address - Street 1:19221 108TH AVE SE
Practice Address - Street 2:SUITE 2
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-7369
Practice Address - Country:US
Practice Address - Phone:253-852-0206
Practice Address - Fax:253-852-6351
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000093421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice