Provider Demographics
NPI:1871501718
Name:NELSON, STEPHEN WAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
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 1:235 N SAN MATEO DR
Mailing Address - Street 2:#200
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2672
Mailing Address - Country:US
Mailing Address - Phone:650-348-7464
Mailing Address - Fax:650-348-8531
Practice Address - Street 1:235 N SAN MATEO DR
Practice Address - Street 2:#200
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2672
Practice Address - Country:US
Practice Address - Phone:650-348-7464
Practice Address - Fax:650-348-8531
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist