Healthcare Provider Details

I. General information

NPI: 1649646795
Provider Name (Legal Business Name): KIP NIELSEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17061 N AVENUE OF THE ARTS STE 101
SUPRISE AZ
85378
US

IV. Provider business mailing address

3658 E ELMWOOD ST
MESA AZ
85205-5165
US

V. Phone/Fax

Practice location:
  • Phone: 623-246-5025
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60590085
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD009895
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: