MEDICARE: DR. HEIDI L. 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	1223G0001X	General Practice Dentistry	033837	NY

General Provider Information

NPI Number	:	1598760522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEIDI L. NELSON D.M.D.

Provider Business Mailing Address
First Line	:	4512 41ST ST
Second Line	:
City	:	SUNNYSIDE
State	:	NY
Zip	:	11104-3419
Country	:	US
Telephone Number	:	718-784-2699
Fax Number	:	718-784-2669

Provider Business Practice Location Address
First Line	:	4512 41ST ST
Second Line	:
City	:	SUNNYSIDE
State	:	NY
Zip	:	11104-3419
Country	:	US
Telephone Number	:	718-784-2699
Fax Number	:	718-784-2669

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/08/2007

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