Provider Demographics
NPI:1508937210
Name:NELSON JR., DONALD BRYCE (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:BRYCE
Last Name:NELSON JR.
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:GA
Mailing Address - Zip Code:31329-9255
Mailing Address - Country:US
Mailing Address - Phone:912-754-6822
Mailing Address - Fax:912-754-4368
Practice Address - Street 1:105 S LAUREL ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:GA
Practice Address - Zip Code:31329-9255
Practice Address - Country:US
Practice Address - Phone:912-754-6822
Practice Address - Fax:912-754-4368
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDNO125431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1687448OtherUNITED CONCORDIA
GA9184109OtherDORAL