Provider Demographics
NPI:1588956031
Name:NELSON, G P (DDS)
Entity type:Individual
Prefix:DR
First Name:G
Middle Name:P
Last Name:NELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:P
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1020 FOURTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101
Mailing Address - Country:US
Mailing Address - Phone:507-831-3717
Mailing Address - Fax:507-831-3718
Practice Address - Street 1:1020 FOURTH AVENUE
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-1440
Practice Address - Country:US
Practice Address - Phone:507-831-3717
Practice Address - Fax:507-831-3718
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice