Healthcare Provider Details

I. General information

NPI: 1962408401
Provider Name (Legal Business Name): DONALD OTTO NELSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 GLEN LAKE RD
HOFFMAN ESTATES IL
60169
US

IV. Provider business mailing address

1475 GLEN LAKE RD
HOFFMAN ESTATES IL
60169
US

V. Phone/Fax

Practice location:
  • Phone: 847-882-2620
  • Fax: 847-882-0254
Mailing address:
  • Phone: 847-882-2620
  • Fax: 847-882-0254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019-013534
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019013534
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: