Provider Demographics
NPI:1720208200
Name:NELSON, PETER B (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:B
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 1:717 NEWFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-1815
Mailing Address - Country:US
Mailing Address - Phone:860-347-1227
Mailing Address - Fax:860-347-5717
Practice Address - Street 1:717 NEWFIELD ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-1815
Practice Address - Country:US
Practice Address - Phone:860-347-1227
Practice Address - Fax:860-347-5717
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0047361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice