Provider Demographics
NPI:1558835652
Name:NELSON, SARA ANN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:ANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-3307
Mailing Address - Country:US
Mailing Address - Phone:701-741-2822
Mailing Address - Fax:
Practice Address - Street 1:636 BROADWAY ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2164
Practice Address - Country:US
Practice Address - Phone:612-843-4751
Practice Address - Fax:612-746-1531
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH9378124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist