Provider Demographics
NPI:1225108186
Name:NELSON, JILL SANDWICK (DDS)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:SANDWICK
Last Name:NELSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 MAIN AVENUE NORTH
Mailing Address - Street 2:PO BOX 299
Mailing Address - City:BAGLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56621
Mailing Address - Country:US
Mailing Address - Phone:218-694-6571
Mailing Address - Fax:
Practice Address - Street 1:13 MAIN AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621
Practice Address - Country:US
Practice Address - Phone:218-694-6571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN109671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice