Healthcare Provider Details

I. General information

NPI: 1558742593
Provider Name (Legal Business Name): J. KIP NIELSON DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10123 LAKE CREEK PKWY BLDG 2
AUSTIN TX
78729-1754
US

IV. Provider business mailing address

10123 LAKE CREEK PKWY BLDG 2
AUSTIN TX
78729-1754
US

V. Phone/Fax

Practice location:
  • Phone: 512-250-8101
  • Fax:
Mailing address:
  • Phone: 512-250-8101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: JED CODY NIELSON
Title or Position: PROVIDER
Credential: DDS
Phone: 512-250-8101