Provider Demographics
NPI:1326420415
Name:NIELSEN, TRENT (DDS)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:
Last Name:NIELSEN
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 1:12417 W ENCANTO BLVD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-6515
Mailing Address - Country:US
Mailing Address - Phone:623-533-2875
Mailing Address - Fax:
Practice Address - Street 1:12417 W ENCANTO BLVD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-6515
Practice Address - Country:US
Practice Address - Phone:623-533-2875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0092731223D0004X
TX309371223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist