MEDICARE: DR. JED CODY NIELSON 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	7543	AZ
2	1223G0001X	General Practice Dentistry	29379	TX
3	1223E0200X	Endodontics	29379	TX

General Provider Information

NPI Number	:	1598929143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JED CODY NIELSON DDS

Provider Business Mailing Address
First Line	:	10123 LAKE CREEK PKWY
Second Line	:	BUILDING 2
City	:	AUSTIN
State	:	TX
Zip	:	78729-1756
Country	:	US
Telephone Number	:	512-250-8101
Fax Number	:	512-258-7154

Provider Business Practice Location Address
First Line	:	10123 LAKE CREEK PKWY
Second Line	:	BUILDING 2
City	:	AUSTIN
State	:	TX
Zip	:	78729-1756
Country	:	US
Telephone Number	:	512-250-8101
Fax Number	:	512-258-7154

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

Provider Enumeration Date	:	07/14/2008
Last Update Date	:	01/07/2014

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