Provider Demographics
NPI:1629150198
Name:NELSON, DALE DONALDSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:DONALDSON
Last Name:NELSON
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 1:910 NE MINNEHAHA ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8750
Mailing Address - Country:US
Mailing Address - Phone:360-696-9461
Mailing Address - Fax:360-699-7199
Practice Address - Street 1:910 NE MINNEHAHA ST
Practice Address - Street 2:SUITE 12
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8750
Practice Address - Country:US
Practice Address - Phone:360-696-9461
Practice Address - Fax:360-699-7199
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000069281223G0001X
CA378841223G0001X
ORD66221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice