Provider Demographics
NPI:1265875777
Name:KEITH V NELSON DDS PC
Entity type:Organization
Organization Name:KEITH V NELSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:V
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-556-8917
Mailing Address - Street 1:21163 NEWPORT COAST DR
Mailing Address - Street 2:STE 211
Mailing Address - City:NEWPORT COAST
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1123
Mailing Address - Country:US
Mailing Address - Phone:801-556-8917
Mailing Address - Fax:801-618-3913
Practice Address - Street 1:15022 MULBERRY DR
Practice Address - Street 2:#F
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90604-4445
Practice Address - Country:US
Practice Address - Phone:801-556-8917
Practice Address - Fax:801-618-3913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty