Provider Demographics
NPI:1558423384
Name:NELSON, GARY LEE (DMD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:NELSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 DELAWARE AVENUE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054
Mailing Address - Country:US
Mailing Address - Phone:518-439-9994
Mailing Address - Fax:518-439-4152
Practice Address - Street 1:274 DELAWARE AVENUE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054
Practice Address - Country:US
Practice Address - Phone:518-439-9994
Practice Address - Fax:518-439-4152
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02937311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice