Provider Demographics
NPI:1871755991
Name:PAUL E. NELSON D.D.S.
Entity type:Organization
Organization Name:PAUL E. NELSON D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-777-3009
Mailing Address - Street 1:2377 MARGARET ST N
Mailing Address - Street 2:
Mailing Address - City:NORTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-3019
Mailing Address - Country:US
Mailing Address - Phone:651-777-3009
Mailing Address - Fax:651-777-0307
Practice Address - Street 1:2377 MARGARET ST N
Practice Address - Street 2:
Practice Address - City:NORTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3019
Practice Address - Country:US
Practice Address - Phone:651-777-3009
Practice Address - Fax:651-777-0307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN693517600Medicaid