Provider Demographics
NPI:1356622401
Name:NIELSEN, MATTHEW JOHN (DDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:NIELSEN
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 1:5955 ZEAMER AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3702
Mailing Address - Country:US
Mailing Address - Phone:907-580-5010
Mailing Address - Fax:
Practice Address - Street 1:224 W D.L. INGRAM
Practice Address - Street 2:BLD. 1408
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:575-784-4041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-105031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice