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General NPI Number Information
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NPI Number | 1629427182
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Entity Type | Individual
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Provider Name | DANE NELSON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 06/06/2016
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Last Update Date | 06/06/2016
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Provider Practice Location Address
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Address Line | 2410 SAMPSON ST CAPTAIN JAMES A. LOVELL FEDERAL HEALTH CARE CENTER
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City | GREAT LAKES
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State | IL
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Zip | 60088-2942
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Country | US
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Telephone | 651-226-3562
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Fax |
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Provider Business Mailing Address
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Address Line | 1575 OAK AVE APT 12
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City | EVANSTON
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State | IL
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Zip | 60201-4249
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Country | US
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Telephone |
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Fax |
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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 | D13673
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License Number State | MN
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