MEDICARE: FLAMINGO RD NIELSON PDC PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1223P0300X	Periodontics
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
3	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1588454367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLAMINGO RD NIELSON PDC PLLC

Provider Business Mailing Address
First Line	:	727 E UTAH VALLEY DR
Second Line	:
City	:	AMERICAN FORK
State	:	UT
Zip	:	84003-3345
Country	:	US
Telephone Number	:	801-305-3460
Fax Number	:

Provider Business Practice Location Address
First Line	:	5680 W FLAMINGO RD STE B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-2339
Country	:	US
Telephone Number	:	702-367-1499
Fax Number	:	702-367-2531

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	MARK CHRISTENSEN
Credential	:
Telephone Number	:	801-305-3460

Provider Enumeration Date	:	05/07/2025
Last Update Date	:	05/07/2025

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