MEDICARE: TASHIBA I NELSON D.M.D

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	LNO6123	AL

General Provider Information

NPI Number	:	1518306190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TASHIBA I NELSON D.M.D

Provider Business Mailing Address
First Line	:	60 CENTER ST
Second Line	:
City	:	WINDSOR
State	:	CT
Zip	:	06095-1402
Country	:	US
Telephone Number	:	860-255-4197
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 CENTER ST
Second Line	:
City	:	WINDSOR
State	:	CT
Zip	:	06095-1402
Country	:	US
Telephone Number	:	860-255-4197
Fax Number	:

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

Provider Enumeration Date	:	06/18/2013
Last Update Date	:	04/13/2015

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