Provider Demographics
NPI:1750954558
Name:NELSON, MATTHEW A (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
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 1:4205 RANSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3008
Mailing Address - Country:US
Mailing Address - Phone:808-548-1333
Mailing Address - Fax:
Practice Address - Street 1:701 E CATHEDRAL RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2128
Practice Address - Country:US
Practice Address - Phone:800-277-3633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS043365122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist