Healthcare Provider Details

I. General information

NPI: 1275601395
Provider Name (Legal Business Name): KEITH VICTOR NELSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6183 S PRAIRIE VIEW DR SUITE 101
SALT LAKE CITY UT
84129-3203
US

IV. Provider business mailing address

6183 S PRAIRIE VIEW DR SUITE 101
SALT LAKE CITY UT
84129-3203
US

V. Phone/Fax

Practice location:
  • Phone: 801-968-9147
  • Fax: 801-966-2932
Mailing address:
  • Phone: 801-968-9147
  • Fax: 801-966-2932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number62277
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5032263-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: