=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336211408
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT J. NELSON D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 01/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 427 CENTERSTONE CT
-----------------------------------------------------
City | ZEELAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49464-2247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-748-4100
-----------------------------------------------------
Fax | 616-748-0608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 427 CENTERSTONE CT
-----------------------------------------------------
City | ZEELAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49464-2247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-748-4100
-----------------------------------------------------
Fax | 616-748-0608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 17634
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------