Provider Demographics
NPI:1346300217
Name:NELSON, SANDRA RAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:RAE
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 1:2114 WATER LILLY LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1930
Mailing Address - Country:US
Mailing Address - Phone:651-707-0536
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S STE 390
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2121
Practice Address - Country:US
Practice Address - Phone:952-926-3534
Practice Address - Fax:952-926-7085
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND108611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice