Healthcare Provider Details

I. General information

NPI: 1811915499
Provider Name (Legal Business Name): J DENNIS NELSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 BROADWAY N
FARGO ND
58122-0001
US

IV. Provider business mailing address

253 CENTRAL AVE N
VALLEY CITY ND
58072-2941
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-4811
  • Fax: 701-234-6979
Mailing address:
  • Phone: 701-845-1511
  • Fax: 701-845-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number335
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: