Provider Demographics
NPI:1932119054
Name:NELSON, MICHAEL S (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
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:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-0385
Mailing Address - Country:US
Mailing Address - Phone:870-423-4042
Mailing Address - Fax:870-423-7173
Practice Address - Street 1:1122 W TRIMBLE AVE STE A
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-5248
Practice Address - Country:US
Practice Address - Phone:870-423-4042
Practice Address - Fax:870-423-7173
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR32161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T702OtherBLUE CROSS BLUE SHIELD ID
ARAR3216OtherSTATE LICENSE I.D.
AR1653236OtherUNITED CONCORDIA I.D.