Provider Demographics
NPI:1760404495
Name:NIELSON, ERIC REID (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:REID
Last Name:NIELSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 S ELLSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-2160
Mailing Address - Country:US
Mailing Address - Phone:480-357-9444
Mailing Address - Fax:
Practice Address - Street 1:3035 S ELLSWORTH RD
Practice Address - Street 2:138
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-2160
Practice Address - Country:US
Practice Address - Phone:480-357-9442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD61051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice