MEDICARE: DR. MICHAEL D 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	55899	CA
2	122300000X	Dentist	D-4201	ID

General Provider Information

NPI Number	:	1417136474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL D NELSON D.D.S.

Provider Business Mailing Address
First Line	:	412 W MAIN ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1447
Country	:	US
Telephone Number	:	208-983-2422
Fax Number	:	208-983-3404

Provider Business Practice Location Address
First Line	:	412 W MAIN ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1447
Country	:	US
Telephone Number	:	208-983-2422
Fax Number	:	208-983-3404

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

Provider Enumeration Date	:	10/26/2007
Last Update Date	:	02/18/2009

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