Provider Demographics
NPI:1578583654
Name:NELSON, WILLIAM J (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
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 1:2581 DEVELOPMENT DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4247
Mailing Address - Country:US
Mailing Address - Phone:920-347-0400
Mailing Address - Fax:920-347-0868
Practice Address - Street 1:2581 DEVELOPMENT DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4247
Practice Address - Country:US
Practice Address - Phone:920-347-0400
Practice Address - Fax:920-347-0868
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27821223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI002607650Medicare ID - Type Unspecified
T62860Medicare UPIN