Provider Demographics
NPI:1801057492
Name:NELSON, MATTHEW ANSON (DDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ANSON
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 1:1120 LANSDALE LN
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-1673
Mailing Address - Country:US
Mailing Address - Phone:608-220-6842
Mailing Address - Fax:
Practice Address - Street 1:2805 LIBAL ST
Practice Address - Street 2:SUITE A
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2877
Practice Address - Country:US
Practice Address - Phone:920-336-6062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6248-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist