Healthcare Provider Details

I. General information

NPI: 1568684272
Provider Name (Legal Business Name): FREDERIC CLYDE NELSON JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 A HOSPITAL ROAD WALKER RIVER DENTAL CLINIC
SCHURZ NV
89427
US

IV. Provider business mailing address

23910 VIA HAMACA
VALENCIA CA
91355-2811
US

V. Phone/Fax

Practice location:
  • Phone: 661-904-7400
  • Fax:
Mailing address:
  • Phone: 661-904-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21177
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: