Healthcare Provider Details

I. General information

NPI: 1629166590
Provider Name (Legal Business Name): JACK ANDREW NELSON OMFS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 W MONTAUK HWY
HAMPTON BAYS NY
11946-3510
US

IV. Provider business mailing address

240 W MONTAUK HWY
HAMPTON BAYS NY
11946-3510
US

V. Phone/Fax

Practice location:
  • Phone: 631-728-1300
  • Fax: 631-728-5165
Mailing address:
  • Phone: 631-728-1300
  • Fax: 631-728-5165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0429341
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: