Provider Demographics
NPI:1972760916
Name:RICK NELSON ENDODONTIC PC
Entity Type:Organization
Organization Name:RICK NELSON ENDODONTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:515-223-0602
Mailing Address - Street 1:974 73RD STREET
Mailing Address - Street 2:SUITE 18
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50312-1026
Mailing Address - Country:US
Mailing Address - Phone:515-223-0602
Mailing Address - Fax:515-223-7346
Practice Address - Street 1:974 73RD ST
Practice Address - Street 2:SUITE 18
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50312-1024
Practice Address - Country:US
Practice Address - Phone:515-223-0602
Practice Address - Fax:515-223-7346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06911305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1922095983OtherTYPE 1 NPI#