Provider Demographics
NPI:1992719280
Name:NELLEN, RONALD HENRY (DDS)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:HENRY
Last Name:NELLEN
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 1:4811 S 76TH ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4364
Mailing Address - Country:US
Mailing Address - Phone:414-281-3344
Mailing Address - Fax:414-281-1080
Practice Address - Street 1:4811 S 76TH ST
Practice Address - Street 2:SUITE 304
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4364
Practice Address - Country:US
Practice Address - Phone:414-281-3344
Practice Address - Fax:414-281-1080
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT62850Medicare UPIN
WI79402Medicare ID - Type UnspecifiedPROVIDER ID NUMBER