MEDICARE: DR. KEITH VICTOR NELSON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5032263-9922	UT
2	122300000X	Dentist	62277	CA

General Provider Information

NPI Number	:	1275601395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH VICTOR NELSON D.D.S.

Provider Business Mailing Address
First Line	:	6183 S PRAIRIE VIEW DR
Second Line	:	SUITE 101
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84129-3203
Country	:	US
Telephone Number	:	801-968-9147
Fax Number	:	801-966-2932

Provider Business Practice Location Address
First Line	:	6183 S PRAIRIE VIEW DR
Second Line	:	SUITE 101
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84129-3203
Country	:	US
Telephone Number	:	801-968-9147
Fax Number	:	801-966-2932

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	04/17/2013

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