Provider Demographics
NPI:1396950176
Name:NELSON, CRAIG LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:LEE
Last Name:NELSON
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 1:405 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-2234
Mailing Address - Country:US
Mailing Address - Phone:260-463-3123
Mailing Address - Fax:
Practice Address - Street 1:405 UNION ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-2234
Practice Address - Country:US
Practice Address - Phone:260-463-3123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006413A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100159780AMedicaid