Provider Demographics
NPI:1689720161
Name:NELSON, PETER B (DMD, PC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:B
Last Name:NELSON
Suffix:
Gender:M
Credentials:DMD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3699
Mailing Address - Country:US
Mailing Address - Phone:406-752-8302
Mailing Address - Fax:
Practice Address - Street 1:795 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3699
Practice Address - Country:US
Practice Address - Phone:406-752-8302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT13971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT011-2554Medicaid