Provider Demographics
NPI:1306861653
Name:NELSON, CRAIG LIVEZEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:LIVEZEY
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 1:1257 WATERFRONT DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-9494
Mailing Address - Country:US
Mailing Address - Phone:843-849-7046
Mailing Address - Fax:
Practice Address - Street 1:VA HEALTH CARE SYSTEM
Practice Address - Street 2:10,000 BAY PINES BOULVARD
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33708
Practice Address - Country:US
Practice Address - Phone:727-398-9396
Practice Address - Fax:727-319-1146
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33401223P0700X
SC4751223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3340OtherDENTAL LICENSE