Provider Demographics
NPI:1649397381
Name:NELSON, WAYNE GERARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:GERARD
Last Name:NELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 SPRING BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-2913
Mailing Address - Country:US
Mailing Address - Phone:810-220-7935
Mailing Address - Fax:
Practice Address - Street 1:2700 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8533
Practice Address - Country:US
Practice Address - Phone:517-546-7211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016668122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist