Provider Demographics
NPI:1831565969
Name:NELSON, ANNELISE (DDS)
Entity type:Individual
Prefix:
First Name:ANNELISE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15535 34TH AVE N STE 250
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-2171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15535 34TH AVE N STE 250
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-2171
Practice Address - Country:US
Practice Address - Phone:763-233-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND136051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice