Provider Demographics
NPI:1629111901
Name:NELSON-CHRYSTAL, TANIA (DDS)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:NELSON-CHRYSTAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2771 COURTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-7936
Mailing Address - Country:US
Mailing Address - Phone:443-519-6540
Mailing Address - Fax:916-244-2714
Practice Address - Street 1:9323 LAGUNA SPRINGS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7838
Practice Address - Country:US
Practice Address - Phone:916-689-7837
Practice Address - Fax:916-330-4390
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA594421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program