Provider Demographics
NPI:1366736357
Name:NIELSON, BRANDON LARS (DMD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:LARS
Last Name:NIELSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1297 MAIN ST.
Mailing Address - Street 2:SUITE3
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550
Mailing Address - Country:US
Mailing Address - Phone:970-686-7775
Mailing Address - Fax:970-686-5892
Practice Address - Street 1:1297 MAIN ST.
Practice Address - Street 2:SUITE3
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550
Practice Address - Country:US
Practice Address - Phone:970-686-7775
Practice Address - Fax:970-686-5892
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10451122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist