Healthcare Provider Details

I. General information

NPI: 1679579692
Provider Name (Legal Business Name): KHARI NELSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 HWY 104
IONE CA
95640
US

IV. Provider business mailing address

PO BOX 409099
IONE CA
95640-9099
US

V. Phone/Fax

Practice location:
  • Phone: 916-601-0351
  • Fax:
Mailing address:
  • Phone: 916-601-0351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number47762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: