Provider Demographics
NPI:1013120138
Name:NELSON, ELLEN MARIE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:MARIE
Last Name:NELSON
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 561 BOX 1783
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310-0018
Mailing Address - Country:US
Mailing Address - Phone:315-255-8500
Mailing Address - Fax:
Practice Address - Street 1:900 PALM VALLEY BLVD
Practice Address - Street 2:STE 1017
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664
Practice Address - Country:US
Practice Address - Phone:512-255-4444
Practice Address - Fax:512-255-1750
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX162161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics