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General NPI Number Information
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NPI Number | 1609983931
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Entity Type | Organization
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Legal Business Name | GARY S NELSON DMD INC
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Dates
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Enumeration Date | 08/24/2006
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Last Update Date | 07/01/2011
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Provider Practice Location Address
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Address Line | 21 FORT EVANS RD NE STE E
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City | LEESBURG
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State | VA
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Zip | 20176-4488
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Country | US
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Telephone | 703-777-7307
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Fax | 703-777-7840
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Provider Business Mailing Address
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Address Line | 21 FORT EVANS RD NE STE E
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City | LEESBURG
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State | VA
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Zip | 20176-4488
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Country | US
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Telephone | 703-777-7307
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Fax | 703-777-7840
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Authorized Official
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Title or Position | PRESIDENT
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Name | GARY S NELSON
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Credential | DMD
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Telephone | 703-777-7307
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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 | 0401007110
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License Number State | VA
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