MEDICARE: DR. SHELBY NELSON DDS, LLC

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	261QD0000X	Dental Clinic/Center
2	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1669026555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. SHELBY NELSON DDS, LLC

Provider Business Mailing Address
First Line	:	3833 CAMP BOWIE BLVD
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76107-3355
Country	:	US
Telephone Number	:	817-738-2334
Fax Number	:

Provider Business Practice Location Address
First Line	:	3833 CAMP BOWIE BLVD
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76107-3355
Country	:	US
Telephone Number	:	817-738-2334
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SHELBY NELSON
Credential	:
Telephone Number	:	214-454-3816

Provider Enumeration Date	:	07/29/2019
Last Update Date	:	06/26/2024

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