Provider Demographics
NPI:1457442774
Name:NELSON, GRANT DANIEL (DDS)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:DANIEL
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 1:324 W SUPERIOR ST STE 700
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1721
Mailing Address - Country:US
Mailing Address - Phone:218-722-7831
Mailing Address - Fax:
Practice Address - Street 1:324 W SUPERIOR ST STE 700
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1721
Practice Address - Country:US
Practice Address - Phone:218-722-7831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11583122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist