Provider Demographics
NPI:1104974401
Name:NIELSON, DENNIS EARL (OD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:EARL
Last Name:NIELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 S GOSHEN WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-8570
Mailing Address - Country:US
Mailing Address - Phone:208-322-6161
Mailing Address - Fax:
Practice Address - Street 1:1012 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2304
Practice Address - Country:US
Practice Address - Phone:208-888-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV7310OtherBLUE CROSS
ID0644950001OtherDMERC
ID15254OtherBLUE SHIELD
IDT44303Medicare UPIN
ID15254OtherBLUE SHIELD