Provider Demographics
NPI:1649791880
Name:NELSON, BRETT T (DDS)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:T
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 1:340 EAST 1ST AVENUE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020
Mailing Address - Country:US
Mailing Address - Phone:303-466-4646
Mailing Address - Fax:
Practice Address - Street 1:340 EAST 1ST AVENUE
Practice Address - Street 2:SUITE 202
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020
Practice Address - Country:US
Practice Address - Phone:303-466-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2019-07-31
Deactivation Date:2019-07-15
Deactivation Code:
Reactivation Date:2019-07-24
Provider Licenses
StateLicense IDTaxonomies
CODEN.002032271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000173385Medicaid