Provider Demographics
NPI:1992871586
Name:THEODORE R. NELSON, DDS, PC
Entity type:Organization
Organization Name:THEODORE R. NELSON, DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:978-365-5302
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:S LANCASTER
Mailing Address - State:MA
Mailing Address - Zip Code:01561-0607
Mailing Address - Country:US
Mailing Address - Phone:978-365-5302
Mailing Address - Fax:978-598-7072
Practice Address - Street 1:387 STERLING ST
Practice Address - Street 2:
Practice Address - City:S. LANCASTER
Practice Address - State:MA
Practice Address - Zip Code:01561
Practice Address - Country:US
Practice Address - Phone:978-365-5302
Practice Address - Fax:978-598-7072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA163841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty