Healthcare Provider Details

I. General information

NPI: 1760845978
Provider Name (Legal Business Name): PETER S. NELSON, DDS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 W THUNDERBIRD RD H850
GLENDALE AZ
85306-4660
US

IV. Provider business mailing address

5750 W THUNDERBIRD RD H850
GLENDALE AZ
85306-4660
US

V. Phone/Fax

Practice location:
  • Phone: 602-938-0880
  • Fax: 602-547-0528
Mailing address:
  • Phone: 602-938-0880
  • Fax: 602-547-0528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD009095
License Number StateAZ

VIII. Authorized Official

Name: PETER S NELSON
Title or Position: OWNER
Credential: DDS
Phone: 602-938-0880