Provider Demographics
NPI:1316376429
Name:NELSON, PHYLLIS (RDH)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 PACIFIC AVENUE. STE 300
Mailing Address - Street 2:COMMUNITY HEALTH CARE
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402
Mailing Address - Country:US
Mailing Address - Phone:253-722-1540
Mailing Address - Fax:253-722-1546
Practice Address - Street 1:1202 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3926
Practice Address - Country:US
Practice Address - Phone:253-597-3813
Practice Address - Fax:253-597-3815
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00006664124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist