MEDICARE: PETER B. NELSON DMD, PC

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	1223P0221X	Pediatric Dentistry	MT1397	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689720161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER B. NELSON DMD, PC

Provider Business Mailing Address
First Line	:	795 SUNSET BLVD
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-3699
Country	:	US
Telephone Number	:	406-752-8302
Fax Number	:

Provider Business Practice Location Address
First Line	:	795 SUNSET BLVD
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-3699
Country	:	US
Telephone Number	:	406-752-8302
Fax Number	:

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

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	07/08/2007

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