Provider Demographics
NPI:1700954518
Name:NELSON, GARY J (DMD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:NELSON
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 1:3350 S 15TH E
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8321
Mailing Address - Country:US
Mailing Address - Phone:208-522-4700
Mailing Address - Fax:208-522-5416
Practice Address - Street 1:3350 S 15TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8321
Practice Address - Country:US
Practice Address - Phone:208-522-4700
Practice Address - Fax:208-522-5416
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-36311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID61161OtherBLUE CROSS
ID1465021OtherUNITED CONCORDIA