Provider Demographics
NPI:1346505070
Name:NELSON, DEVIN V (DMD)
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:V
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 1:545 CHEYENNE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5323
Mailing Address - Country:US
Mailing Address - Phone:307-789-9034
Mailing Address - Fax:307-789-9065
Practice Address - Street 1:545 CHEYENNE DR
Practice Address - Street 2:SUITE C
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5323
Practice Address - Country:US
Practice Address - Phone:307-789-9034
Practice Address - Fax:307-789-9065
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY13171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice