Provider Demographics
NPI:1598929143
Name:NIELSON, JED CODY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JED
Middle Name:CODY
Last Name:NIELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:J
Other - Middle Name:CODY
Other - Last Name:NIELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10123 LAKE CREEK PKWY
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-1756
Mailing Address - Country:US
Mailing Address - Phone:512-250-8101
Mailing Address - Fax:512-258-7154
Practice Address - Street 1:10123 LAKE CREEK PKWY
Practice Address - Street 2:BUILDING 2
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-1756
Practice Address - Country:US
Practice Address - Phone:512-250-8101
Practice Address - Fax:512-258-7154
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ75431223G0001X
TX293791223G0001X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice