Provider Demographics
NPI:1598784787
Name:NELSON, LEONARD DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:DOUGLAS
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 1:1161 MED PARK DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3238
Mailing Address - Country:US
Mailing Address - Phone:505-523-6414
Mailing Address - Fax:505-523-6614
Practice Address - Street 1:1161 MED PARK DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3238
Practice Address - Country:US
Practice Address - Phone:505-523-6414
Practice Address - Fax:505-523-6614
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM9801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice