Provider Demographics
NPI:1962408401
Name:NELSON, DONALD OTTO (DDS)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:OTTO
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 1:1475 GLEN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169
Mailing Address - Country:US
Mailing Address - Phone:847-882-2620
Mailing Address - Fax:847-882-0254
Practice Address - Street 1:1475 GLEN LAKE RD
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169
Practice Address - Country:US
Practice Address - Phone:847-882-2620
Practice Address - Fax:847-882-0254
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-013534122300000X
IL0190135341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist