Provider Demographics
NPI:1215997663
Name:NELSON, MARK L (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:NELSON
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR
Mailing Address - Street 2:SUITE 540
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7667
Mailing Address - Country:US
Mailing Address - Phone:801-295-8322
Mailing Address - Fax:801-295-7694
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR
Practice Address - Street 2:SUITE 540
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7667
Practice Address - Country:US
Practice Address - Phone:801-295-8322
Practice Address - Fax:801-295-7694
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT1418021223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870542081OtherTAX ID FOR MISC INSURANCE
UT562460OtherUNITED CONCORDIA