Provider Demographics
NPI:1063400901
Name:NELSON, MARK JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:NELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14450 S ROBERT TRL
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-4952
Mailing Address - Country:US
Mailing Address - Phone:651-423-1181
Mailing Address - Fax:
Practice Address - Street 1:14450 S ROBER TR
Practice Address - Street 2:DAKOTA DENTAL AND IMPLANT CENTER
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068
Practice Address - Country:US
Practice Address - Phone:651-423-1181
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice