Provider Demographics
NPI:1134193345
Name:NELSEN, BRENT E (DMD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:E
Last Name:NELSEN
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 1:1120 N ROCK RD
Mailing Address - Street 2:STE 100
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037
Mailing Address - Country:US
Mailing Address - Phone:316-789-9999
Mailing Address - Fax:316-789-9296
Practice Address - Street 1:1120 N ROCK RD
Practice Address - Street 2:STE 100
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037
Practice Address - Country:US
Practice Address - Phone:316-789-9999
Practice Address - Fax:316-789-9296
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS71931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
551227OtherUNITED CONCORDIA