Provider Demographics
NPI:1649445453
Name:NELSON FAMILY DENTISTRY
Entity type:Organization
Organization Name:NELSON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-564-9994
Mailing Address - Street 1:1109 HIGHWAY 70 N
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-8232
Mailing Address - Country:US
Mailing Address - Phone:580-564-9994
Mailing Address - Fax:
Practice Address - Street 1:1109 HIGHWAY 70 N
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-8232
Practice Address - Country:US
Practice Address - Phone:580-564-9994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFREY R. NELSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty