Provider Demographics
NPI:1992815294
Name:NELSON, RYAN M (DDS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:M
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 1078
Mailing Address - Street 2:420 MAIN STREET
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054
Mailing Address - Country:US
Mailing Address - Phone:701-683-7695
Mailing Address - Fax:701-683-7698
Practice Address - Street 1:420 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054
Practice Address - Country:US
Practice Address - Phone:701-683-7695
Practice Address - Fax:701-683-7698
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist