Provider Demographics
NPI:1558742593
Name:J. KIP NIELSON DDS PLLC
Entity Type:Organization
Organization Name:J. KIP NIELSON DDS PLLC
Other - Org Name:STARLIGHT DENTAL AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JED
Authorized Official - Middle Name:CODY
Authorized Official - Last Name:NIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-250-8101
Mailing Address - Street 1:10123 LAKE CREEK PKWY
Mailing Address - Street 2:BLDG 2
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-1754
Mailing Address - Country:US
Mailing Address - Phone:512-250-8101
Mailing Address - Fax:
Practice Address - Street 1:10123 LAKE CREEK PKWY
Practice Address - Street 2:BLDG 2
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-1754
Practice Address - Country:US
Practice Address - Phone:512-250-8101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty