=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487729901
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT DEE NIELSON DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3151 17TH STREET
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-529-3836
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 695 TIE BREAKER DR
-----------------------------------------------------
City | AMMON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83406-4560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-529-3836
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | D3698
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------