Healthcare Provider Details

I. General information

NPI: 1134193345
Provider Name (Legal Business Name): BRENT E NELSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 N ROCK RD STE 100
DERBY KS
67037
US

IV. Provider business mailing address

1120 N ROCK RD STE 100
DERBY KS
67037
US

V. Phone/Fax

Practice location:
  • Phone: 316-789-9999
  • Fax: 316-789-9296
Mailing address:
  • Phone: 316-789-9999
  • Fax: 316-789-9296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7193
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: