Provider Demographics
NPI:1790045193
Name:NELSON, KIM (DH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 4TH AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HOLDREGE
Mailing Address - State:NE
Mailing Address - Zip Code:68949-2255
Mailing Address - Country:US
Mailing Address - Phone:308-995-4778
Mailing Address - Fax:
Practice Address - Street 1:701 4TH AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:HOLDREGE
Practice Address - State:NE
Practice Address - Zip Code:68949-2255
Practice Address - Country:US
Practice Address - Phone:308-995-4778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1623124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist