Healthcare Provider Details

I. General information

NPI: 1558305326
Provider Name (Legal Business Name): CRAIG L NELSON DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 UNION STREET
LAGRANGE IN
46761
US

IV. Provider business mailing address

405 UNION STREET
LAGRANGE IN
46761
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-3123
  • Fax:
Mailing address:
  • Phone: 260-463-3123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12006413A
License Number StateIN

VIII. Authorized Official

Name: DR. CRAIG L NELSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 260-463-3123