Healthcare Provider Details

I. General information

NPI: 1992815294
Provider Name (Legal Business Name): RYAN M NELSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 MAIN STREET
LISBON ND
58054
US

IV. Provider business mailing address

PO BOX 1078 420 MAIN STREET
LISBON ND
58054
US

V. Phone/Fax

Practice location:
  • Phone: 701-683-7695
  • Fax: 701-683-7698
Mailing address:
  • Phone: 701-683-7695
  • Fax: 701-683-7698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1948
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: