Provider Demographics
NPI:1659965770
Name:NELSON, DAMIEN WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:DAMIEN
Middle Name:WILLIAM
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 1:28130 N DARRELL RD
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-9723
Mailing Address - Country:US
Mailing Address - Phone:773-615-0133
Mailing Address - Fax:
Practice Address - Street 1:220 FALCON PKWY
Practice Address - Street 2:
Practice Address - City:SCHRIEVER AFB
Practice Address - State:CO
Practice Address - Zip Code:80912-5005
Practice Address - Country:US
Practice Address - Phone:719-567-5065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002658-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty