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General NPI Number Information
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NPI Number | 1265875777
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Entity Type | Organization
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Legal Business Name | KEITH V NELSON DDS PC
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Dates
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Enumeration Date | 04/15/2013
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Last Update Date | 04/15/2013
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Provider Practice Location Address
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Address Line | 15022 MULBERRY DR #F
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City | WHITTIER
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State | CA
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Zip | 90604-4445
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Country | US
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Telephone | 801-556-8917
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Fax | 801-618-3913
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Provider Business Mailing Address
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Address Line | 21163 NEWPORT COAST DR STE 211
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City | NEWPORT COAST
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State | CA
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Zip | 92657-1123
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Country | US
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Telephone | 801-556-8917
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Fax | 801-618-3913
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEITH V NELSON
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Credential | DDS
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Telephone | 801-556-8917
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 62277
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License Number State | CA
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