Provider Demographics
NPI:1275601395
Name:NELSON, KEITH VICTOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:VICTOR
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 1:6183 S PRAIRIE VIEW DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84129-3203
Mailing Address - Country:US
Mailing Address - Phone:801-968-9147
Mailing Address - Fax:801-966-2932
Practice Address - Street 1:6183 S PRAIRIE VIEW DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84129-3203
Practice Address - Country:US
Practice Address - Phone:801-968-9147
Practice Address - Fax:801-966-2932
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5032263-99221223G0001X
CA62277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist