Healthcare Provider Details

I. General information

NPI: 1972760916
Provider Name (Legal Business Name): RICK NELSON ENDODONTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 05/19/2008
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 STREET SUITE 18
WINDSOR HEIGHTS IA
50312-1026
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 Code305R00000X
TaxonomyPreferred Provider Organization
License Number06911
License Number StateIA

VIII. Authorized Official

Name: MR. RICKY DEAN NELSON
Title or Position: PRESIDENT
Credential: DDS,MS
Phone: 515-223-0602