Provider Demographics
NPI:1235271578
Name:NELSON, MICHAEL JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
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 1828
Mailing Address - Street 2:801-A S. LEE
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-1828
Mailing Address - Country:US
Mailing Address - Phone:918-478-4433
Mailing Address - Fax:918-478-4066
Practice Address - Street 1:801 S LEE ST
Practice Address - Street 2:SUITE A
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434-8710
Practice Address - Country:US
Practice Address - Phone:918-478-4433
Practice Address - Fax:918-478-4066
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK50801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice