Healthcare Provider Details

I. General information

NPI: 1184762643
Provider Name (Legal Business Name): KEITH T. NELSON, DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2007
Last Update Date: 03/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 TELEGRAPH AVE SUITE 234
BERKELEY CA
94705-2051
US

IV. Provider business mailing address

3031 TELEGRAPH AVE SUITE 234
BERKELEY CA
94705-2051
US

V. Phone/Fax

Practice location:
  • Phone: 510-548-9114
  • Fax: 510-548-8046
Mailing address:
  • Phone: 510-548-9114
  • Fax: 510-548-8046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number28772
License Number StateCA

VIII. Authorized Official

Name: MICHELE DECARLO
Title or Position: OFFICE MANAGER
Credential:
Phone: 510-548-9114