Healthcare Provider Details

I. General information

NPI: 1053393694
Provider Name (Legal Business Name): GEORGE AUGUSTUS NELSON III D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4643 CAMP COLEMAN RD SUITE 101
TRUSSVILLE AL
35173-2821
US

IV. Provider business mailing address

4643 CAMP COLEMAN RD SUITE 101
TRUSSVILLE AL
35173-2821
US

V. Phone/Fax

Practice location:
  • Phone: 205-655-0603
  • Fax: 205-655-0693
Mailing address:
  • Phone: 205-655-0603
  • Fax: 205-655-0693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3186
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: