Healthcare Provider Details

I. General information

NPI: 1922095983
Provider Name (Legal Business Name): RICKY DEAN NELSON D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

974 73RD ST SUITE 18
WINDSOR HEIGHTS IA
50312-1024
US

IV. Provider business mailing address

974 73RD ST SUITE 18
WINDSOR HEIGHTS IA
50312-1024
US

V. Phone/Fax

Practice location:
  • Phone: 515-223-0602
  • Fax: 515-223-7346
Mailing address:
  • Phone: 515-223-0602
  • Fax: 515-223-7346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number06911
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: