Provider Demographics
NPI:1811067952
Name:NELSON, HOWARD L (DDS)
Entity type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:L
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 1:1007 SUSHRUTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401
Mailing Address - Country:US
Mailing Address - Phone:304-263-0991
Mailing Address - Fax:304-274-9546
Practice Address - Street 1:1144 OPAL COURT
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740
Practice Address - Country:US
Practice Address - Phone:301-733-2500
Practice Address - Fax:301-733-9600
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35501223S0112X
MD125071223S0112X
DCDEN59751223S0112X
PADS0353931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4002163000Medicaid
MDDF52OtherBCBS
MDDF52OtherBCBS
WV4002163000Medicaid