=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659965770
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAMIEN WILLIAM NELSON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2021
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2133 PEPPERRELL ST BLDG 3352
-----------------------------------------------------
City | LACKLAND AFB
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78236-5313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-292-6258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28130 N DARRELL RD
-----------------------------------------------------
City | WAUCONDA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60084-9723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-615-0133
-----------------------------------------------------
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 | 1002658-15
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------