Provider Demographics
NPI:1609983931
Name:GARY S NELSON DMD INC
Entity Type:Organization
Organization Name:GARY S NELSON DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-777-7307
Mailing Address - Street 1:21 FORT EVANS RD NE STE E
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-4488
Mailing Address - Country:US
Mailing Address - Phone:703-777-7307
Mailing Address - Fax:703-777-7840
Practice Address - Street 1:21 FORT EVANS RD NE STE E
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-4488
Practice Address - Country:US
Practice Address - Phone:703-777-7307
Practice Address - Fax:703-777-7840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007110122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty