Healthcare Provider Details

I. General information

NPI: 1427378108
Provider Name (Legal Business Name): JEREMY KIP NIELSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KIP NIELSON D.D.S.

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10123 LAKE CREEK PKWY BUILDING 2
AUSTIN TX
78729-1756
US

IV. Provider business mailing address

10123 LAKE CREEK PKWY BUILDING 2
AUSTIN TX
78729-1756
US

V. Phone/Fax

Practice location:
  • Phone: 512-250-8101
  • Fax: 512-258-7154
Mailing address:
  • Phone: 512-250-8101
  • Fax: 512-258-7154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number25461
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number25461
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: