Provider Demographics
NPI:1427192020
Name:NELSON, MARK W (DDS MSD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:NELSON
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 228TH AVE NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074
Mailing Address - Country:US
Mailing Address - Phone:425-369-0366
Mailing Address - Fax:425-369-2966
Practice Address - Street 1:336 228TH AVE NE
Practice Address - Street 2:#300
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98074
Practice Address - Country:US
Practice Address - Phone:425-369-0366
Practice Address - Fax:425-369-2966
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000081281223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics