Provider Demographics
NPI:1669601886
Name:NELSON, KEVIN TED (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TED
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 1:775 E HOLLAND AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-5016
Mailing Address - Country:US
Mailing Address - Phone:509-464-2391
Mailing Address - Fax:509-232-0555
Practice Address - Street 1:775 E HOLLAND AVE STE 201
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-5016
Practice Address - Country:US
Practice Address - Phone:509-464-2391
Practice Address - Fax:509-232-0555
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009015337122300000X
WADE606908901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist