MEDICARE: DR. BC 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	1223D0001X	Public Health Dentistry	D6700	OR

General Provider Information

NPI Number	:	1083600712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BC NELSON DDS

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

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

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

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	07/08/2007

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