Provider Demographics
NPI:1285925156
Name:NELSON, MATTHEW EDGAR (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:EDGAR
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 1:5200 GREYSTONE SUMMIT DR APT 1008
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-7556
Mailing Address - Country:US
Mailing Address - Phone:269-326-0065
Mailing Address - Fax:
Practice Address - Street 1:7101 HOFF STREET
Practice Address - Street 2:BUILDING 9240 LOVE DENTAL CLINIC
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:269-326-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6736-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist