Provider Demographics
NPI:1417136474
Name:NELSON, MICHAEL D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:NELSON
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 1:412 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1447
Mailing Address - Country:US
Mailing Address - Phone:208-983-2422
Mailing Address - Fax:208-983-3404
Practice Address - Street 1:412 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1447
Practice Address - Country:US
Practice Address - Phone:208-983-2422
Practice Address - Fax:208-983-3404
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55899122300000X
IDD-4201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist