Healthcare Provider Details

I. General information

NPI: 1619030095
Provider Name (Legal Business Name): R. BLAKE NIELSEN D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1434 E 4500 S SUITE #201
SALT LAKE CITY UT
84117-4250
US

IV. Provider business mailing address

1434 E 4500 S SUITE #201
SALT LAKE CITY UT
84117-4250
US

V. Phone/Fax

Practice location:
  • Phone: 801-272-5800
  • Fax: 801-272-5897
Mailing address:
  • Phone: 801-272-5800
  • Fax: 801-272-5897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number90-0144898-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: