Provider Demographics
NPI:1588230403
Name:NELSON, JUSTIN RAY (DMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RAY
Last Name:NELSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1601
Mailing Address - Country:US
Mailing Address - Phone:208-263-8514
Mailing Address - Fax:208-844-2962
Practice Address - Street 1:103 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1601
Practice Address - Country:US
Practice Address - Phone:208-263-8514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61164746122300000X
IDD-5579122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist