Healthcare Provider Details

I. General information

NPI: 1245289123
Provider Name (Legal Business Name): BRYAN NELSON HOUSE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 E HIGHWAY 20 STE 111
NICEVILLE FL
32578-8779
US

IV. Provider business mailing address

1327 WINDWARD CIR
NICEVILLE FL
32578-4310
US

V. Phone/Fax

Practice location:
  • Phone: 850-897-4171
  • Fax:
Mailing address:
  • Phone: 850-897-7588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN15422
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: