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General NPI Number Information
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NPI Number | 1174913578
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Entity Type | Organization
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Legal Business Name | TYLER E NELSON DMD MD INC
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Dates
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Enumeration Date | 01/23/2015
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Last Update Date | 01/23/2015
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Provider Practice Location Address
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Address Line | 2801 WATERMAN BLVD STE 240
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City | FAIRFIELD
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State | CA
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Zip | 94534-2987
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Country | US
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Telephone | 707-428-5427
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Fax |
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Provider Business Mailing Address
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Address Line | 2801 WATERMAN BLVD STE 240
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City | FAIRFIELD
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State | CA
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Zip | 94534-2987
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Country | US
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Telephone | 707-428-5427
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TYLER ELLIOTT NELSON
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Credential | DMD, MD
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Telephone | 707-337-0996
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | 56695
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License Number State | CA
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