Provider Demographics
NPI:1619030095
Name:NIELSEN, R. BLAKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:R.
Middle Name:BLAKE
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 E 4500 S
Mailing Address - Street 2:SUITE #201
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4250
Mailing Address - Country:US
Mailing Address - Phone:801-272-5800
Mailing Address - Fax:801-272-5897
Practice Address - Street 1:1434 E 4500 S
Practice Address - Street 2:SUITE #201
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4250
Practice Address - Country:US
Practice Address - Phone:801-272-5800
Practice Address - Fax:801-272-5897
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT90-0144898-99221223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics