Provider Demographics
NPI:1629166590
Name:NELSON, JACK ANDREW (OMFS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ANDREW
Last Name:NELSON
Suffix:
Gender:M
Credentials:OMFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-3510
Mailing Address - Country:US
Mailing Address - Phone:631-728-1300
Mailing Address - Fax:631-728-5165
Practice Address - Street 1:240 W MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-3510
Practice Address - Country:US
Practice Address - Phone:631-728-1300
Practice Address - Fax:631-728-5165
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04293411223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01548470Medicaid
NYD14271Medicare ID - Type Unspecified
NY01548470Medicaid