MEDICARE: DR. TERESA LEE NELSON DDS, FAGD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1888	MT

General Provider Information

NPI Number	:	1013039742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERESA LEE NELSON DDS, FAGD

Provider Business Mailing Address
First Line	:	50 VILLAGE LOOP RD
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-2793
Country	:	US
Telephone Number	:	406-755-4166
Fax Number	:	406-755-4644

Provider Business Practice Location Address
First Line	:	50 VILLAGE LOOP RD
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-2793
Country	:	US
Telephone Number	:	406-755-4166
Fax Number	:	406-755-4644

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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