Healthcare Provider Details

I. General information

NPI: 1104974401
Provider Name (Legal Business Name): DENNIS EARL NIELSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 N MAIN ST
MERIDIAN ID
83642-2304
US

IV. Provider business mailing address

2804 S GOSHEN WAY
BOISE ID
83709-8570
US

V. Phone/Fax

Practice location:
  • Phone: 208-888-5252
  • Fax:
Mailing address:
  • Phone: 208-322-6161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-498
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: