Provider Demographics
NPI:1801237920
Name:NELSON, JONATHAN EUGENE (DMD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EUGENE
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 1:3700 S RUSSELL ST
Mailing Address - Street 2:STE. #116
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8574
Mailing Address - Country:US
Mailing Address - Phone:406-542-3305
Mailing Address - Fax:406-721-3226
Practice Address - Street 1:3700 S RUSSELL ST
Practice Address - Street 2:STE. #116
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8574
Practice Address - Country:US
Practice Address - Phone:406-542-3305
Practice Address - Fax:406-721-3226
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6667122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist