Provider Demographics
NPI:1154878668
Name:NELSON FAMILY DENTISTRY
Entity type:Organization
Organization Name:NELSON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACY
Authorized Official - Middle Name:C
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-852-0206
Mailing Address - Street 1:19221 108TH AVE SE STE 2
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-7369
Mailing Address - Country:US
Mailing Address - Phone:253-852-0206
Mailing Address - Fax:253-852-5361
Practice Address - Street 1:19221 108TH AVE SE SUITE #2
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055
Practice Address - Country:US
Practice Address - Phone:253-852-0206
Practice Address - Fax:253-852-5361
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NELSON FAMILY DENTISRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE9342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty