Healthcare Provider Details

I. General information

NPI: 1013980242
Provider Name (Legal Business Name): RAND H NELSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR NMCSD, ATTN: MEDICAL STAFF SERVICES
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

34800 BOB WILSON DR NMCSD, ATTN: MEDICAL STAFF SERVICES
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6460
  • Fax: 619-532-6299
Mailing address:
  • Phone: 619-532-6460
  • Fax: 619-532-6299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE00004957
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number52190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: