MEDICARE: DR. MARK JOHN NELSON DDS

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	8675	MN

General Provider Information

NPI Number	:	1063400901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK JOHN NELSON DDS

Provider Business Mailing Address
First Line	:	14450 S ROBERT TRL
Second Line	:
City	:	ROSEMOUNT
State	:	MN
Zip	:	55068-4952
Country	:	US
Telephone Number	:	651-423-1181
Fax Number	:

Provider Business Practice Location Address
First Line	:	14450 S ROBER TR
Second Line	:	DAKOTA DENTAL AND IMPLANT CENTER
City	:	ROSEMOUNT
State	:	MN
Zip	:	55068
Country	:	US
Telephone Number	:	651-423-1181
Fax Number	:

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

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	07/08/2007

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