Provider Demographics
NPI:1649646795
Name:NIELSEN, KIP (DMD)
Entity type:Individual
Prefix:
First Name:KIP
Middle Name:
Last Name:NIELSEN
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 1:3658 E ELMWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-5165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17061 N AVENUE OF THE ARTS
Practice Address - Street 2:STE 101
Practice Address - City:SUPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378
Practice Address - Country:US
Practice Address - Phone:623-246-5025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60590085122300000X
AZD009895122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist