Healthcare Provider Details

I. General information

NPI: 1154333250
Provider Name (Legal Business Name): G P NELSON DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 FOURTH AVENUE
WINDOM MN
56101-1440
US

IV. Provider business mailing address

1020 FOURTH AVENUE
WINDOM MN
56101
US

V. Phone/Fax

Practice location:
  • Phone: 507-831-3717
  • Fax: 507-831-3718
Mailing address:
  • Phone: 507-831-3717
  • Fax: 507-831-3718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8932
License Number StateMN

VIII. Authorized Official

Name: MRS. ADALINE M ROSSOW
Title or Position: OFFICE MANAGER
Credential: RDA CDA
Phone: 507-831-4714