Provider Demographics
NPI:1700915170
Name:NIELSEN, JEFFREY D (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
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 1:222 GRUBER ST
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2525
Mailing Address - Country:US
Mailing Address - Phone:715-623-3324
Mailing Address - Fax:
Practice Address - Street 1:3144 VAN ZILE RD.
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-9001
Practice Address - Country:US
Practice Address - Phone:715-478-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-03
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50021131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice