Provider Demographics
NPI:1417085838
Name:EWOLDSEN, NELS O (DDS)
Entity Type:Individual
Prefix:
First Name:NELS
Middle Name:O
Last Name:EWOLDSEN
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 1:944 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-3438
Mailing Address - Country:US
Mailing Address - Phone:717-849-4597
Mailing Address - Fax:717-849-4515
Practice Address - Street 1:944 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3438
Practice Address - Country:US
Practice Address - Phone:717-849-4597
Practice Address - Fax:717-849-4515
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035348122300000X
WY938122300000X
NE5947122300000X
IN12007599A122300000X
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist