Provider Demographics
NPI:1659082238
Name:NELSON, MATTHEW DOUGLASS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DOUGLASS
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 1:1148 BROADWAY STE 100
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3518
Mailing Address - Country:US
Mailing Address - Phone:253-589-7188
Mailing Address - Fax:
Practice Address - Street 1:1148 BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3518
Practice Address - Country:US
Practice Address - Phone:253-589-7188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61380475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist