Provider Demographics
NPI:1801919527
Name:NELSON, LYLE WILFRED (MD,DMD)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:WILFRED
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD,DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 SE 192ND AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-1469
Mailing Address - Country:US
Mailing Address - Phone:360-256-7100
Mailing Address - Fax:360-256-8886
Practice Address - Street 1:3215 SE 192ND AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1469
Practice Address - Country:US
Practice Address - Phone:360-256-7100
Practice Address - Fax:360-256-8886
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000076051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAE53868Medicare UPIN