Provider Demographics
NPI:1275053621
Name:NELSON, BROCK TYLER (DMD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:TYLER
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 1:2701 STERNBERG DR
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-2060
Mailing Address - Country:US
Mailing Address - Phone:1785-625-7969
Mailing Address - Fax:785-625-4441
Practice Address - Street 1:2701 STERNBERG DR
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2060
Practice Address - Country:US
Practice Address - Phone:1785-625-7969
Practice Address - Fax:785-625-4441
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS614361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice