Provider Demographics
NPI:1962242503
Name:NELSON, KAYLA ROSE (D D S)
Entity type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:ROSE
Last Name:NELSON
Suffix:
Gender:F
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3905
Mailing Address - Country:US
Mailing Address - Phone:701-775-0641
Mailing Address - Fax:701-746-9328
Practice Address - Street 1:4000 17TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3905
Practice Address - Country:US
Practice Address - Phone:701-775-0641
Practice Address - Fax:701-746-9328
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND15076122300000X
ND2511122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist