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General NPI Number Information
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NPI Number | 1417136474
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Entity Type | Individual
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Provider Name | MICHAEL D NELSON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 10/26/2007
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Last Update Date | 02/18/2009
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Provider Practice Location Address
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Address Line | 412 W MAIN ST
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City | GRANGEVILLE
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State | ID
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Zip | 83530-1447
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Country | US
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Telephone | 208-983-2422
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Fax | 208-983-3404
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Provider Business Mailing Address
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Address Line | 412 W MAIN ST
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City | GRANGEVILLE
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State | ID
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Zip | 83530-1447
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Country | US
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Telephone | 208-983-2422
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Fax | 208-983-3404
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 55899
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D-4201
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License Number State | ID
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