MEDICARE: J. KIP NIELSON DDS PLLC

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

General Provider Information

NPI Number	:	1558742593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J. KIP NIELSON DDS PLLC

Provider Business Mailing Address
First Line	:	10123 LAKE CREEK PKWY
Second Line	:	BLDG 2
City	:	AUSTIN
State	:	TX
Zip	:	78729-1754
Country	:	US
Telephone Number	:	512-250-8101
Fax Number	:

Provider Business Practice Location Address
First Line	:	10123 LAKE CREEK PKWY
Second Line	:	BLDG 2
City	:	AUSTIN
State	:	TX
Zip	:	78729-1754
Country	:	US
Telephone Number	:	512-250-8101
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	JED CODY NIELSON
Credential	:	DDS
Telephone Number	:	512-250-8101

Provider Enumeration Date	:	06/16/2015
Last Update Date	:	06/16/2015

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