Healthcare Provider Details

I. General information

NPI: 1457285371
Provider Name (Legal Business Name): JONATHAN WILLIAM NELSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2779 W 4000 S STE 101
ROY UT
84067-9603
US

IV. Provider business mailing address

1943 S 875 E
CLEARFIELD UT
84015-6265
US

V. Phone/Fax

Practice location:
  • Phone: 801-731-5528
  • Fax:
Mailing address:
  • Phone: 801-731-5528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14290632-9923
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: