MEDICARE: B.C. NELSON, D.D.S.

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	122300000X	Dentist	D6700	OR

General Provider Information

NPI Number	:	1053679316
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	B.C. NELSON, D.D.S.

Provider Business Mailing Address
First Line	:	470 E. WASHINGTON ST.
Second Line	:
City	:	STAYON
State	:	OR
Zip	:	97383-1837
Country	:	US
Telephone Number	:	503-769-5210
Fax Number	:	503-769-9172

Provider Business Practice Location Address
First Line	:	470 E. WASHINGTON ST.
Second Line	:
City	:	STAYON
State	:	OR
Zip	:	97383-1837
Country	:	US
Telephone Number	:	503-769-5210
Fax Number	:	503-769-9172

Authorized Official
Title or Position	:	OWNER
Name	:	B.C. NELSON
Credential	:	D.D.S.
Telephone Number	:	503-769-5210

Provider Enumeration Date	:	04/24/2012
Last Update Date	:	04/24/2012

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