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General NPI Number Information
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NPI Number | 1700954518
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Entity Type | Individual
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Provider Name | GARY J NELSON DMD
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Gender | Male
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Dates
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Enumeration Date | 12/01/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3350 S 15TH E
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8321
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Country | US
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Telephone | 208-522-4700
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Fax | 208-522-5416
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Provider Business Mailing Address
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Address Line | 3350 S 15TH E
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8321
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Country | US
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Telephone | 208-522-4700
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Fax | 208-522-5416
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D-3631
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License Number State | ID
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