Provider Demographics
NPI:1326268160
Name:NELSON, KIM LESLIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:LESLIE
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 1:6751 RUFE SNOW DR
Mailing Address - Street 2:SUITE 850
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76148-2319
Mailing Address - Country:US
Mailing Address - Phone:817-656-8777
Mailing Address - Fax:817-581-2073
Practice Address - Street 1:6751 RUFE SNOW DR
Practice Address - Street 2:SUITE 850
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76148-2319
Practice Address - Country:US
Practice Address - Phone:817-656-8777
Practice Address - Fax:817-581-2073
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX159391223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX462833697OtherEIN