Provider Demographics
NPI:1689769135
Name:NELSON, PAUL WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WAYNE
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 1:1200 E BRIN ST
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160-2938
Mailing Address - Country:US
Mailing Address - Phone:972-551-8005
Mailing Address - Fax:
Practice Address - Street 1:1200 E BRIN ST
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160-2938
Practice Address - Country:US
Practice Address - Phone:972-551-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L27514OtherMEDICARE GROUP