MEDICARE: KEITH V NELSON DDS PC

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	122300000X	Dentist	62277	CA
2	122300000X	Dentist	5032263	UT

General Provider Information

NPI Number	:	1316169162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEITH V NELSON DDS PC

Provider Business Mailing Address
First Line	:	6183 S PRAIRIE VIEW DR
Second Line	:	STE 101
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84129-3202
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	:	84129-3202
Country	:	US
Telephone Number	:	801-968-9147
Fax Number	:	801-966-2932

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEITH VICTOR NELSON
Credential	:	DDS
Telephone Number	:	801-968-9147

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/17/2013

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