=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972760916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICK NELSON ENDODONTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2008
-----------------------------------------------------
Last Update Date | 05/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 974 73RD ST SUITE 18
-----------------------------------------------------
City | WINDSOR HEIGHTS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50312-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-223-0602
-----------------------------------------------------
Fax | 515-223-7346
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 974 73RD STREET SUITE 18
-----------------------------------------------------
City | WINDSOR HEIGHTS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50312-1026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-223-0602
-----------------------------------------------------
Fax | 515-223-7346
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RICKY DEAN NELSON
-----------------------------------------------------
Credential | DDS,MS
-----------------------------------------------------
Telephone | 515-223-0602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | 06911
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------