1013120138 NPI number — DR. ELLEN MARIE NELSON D.D.S., M.S.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013120138 NPI number — DR. ELLEN MARIE NELSON D.D.S., M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
ELLEN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S., M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013120138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PSC 561 BOX 1783
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FPO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96310-0018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-255-8500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 PALM VALLEY BLVD
Provider Second Line Business Practice Location Address:
STE 1017
Provider Business Practice Location Address City Name:
ROUND ROCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-255-4444
Provider Business Practice Location Address Fax Number:
512-255-1750
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  16216 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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