MEDICARE: DR. KIM LESLIE NELSON DDS

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	15939	TX
2	122300000X	Dentist	15939	TX

General Provider Information

NPI Number	:	1326268160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM LESLIE NELSON DDS

Provider Business Mailing Address
First Line	:	6751 RUFE SNOW DR
Second Line	:	SUITE 850
City	:	FORT WORTH
State	:	TX
Zip	:	76148-2319
Country	:	US
Telephone Number	:	817-656-8777
Fax Number	:	817-581-2073

Provider Business Practice Location Address
First Line	:	6751 RUFE SNOW DR
Second Line	:	SUITE 850
City	:	FORT WORTH
State	:	TX
Zip	:	76148-2319
Country	:	US
Telephone Number	:	817-656-8777
Fax Number	:	817-581-2073

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/13/2016

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