Basic Information
| Provider Information | |||||||||
| NPI: | 1811946841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEILSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | GENE | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 RED PHEASANT DR | ||||||||
| Address2: | |||||||||
| City: | VACAVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956877748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033679417 | ||||||||
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| Practice Location | |||||||||
| Address1: | 60TH DENTAL SQUADRON | ||||||||
| Address2: | 101 BODIN CIRCLE | ||||||||
| City: | TRAVIS AFB | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074237085 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 11/19/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D8635 | OR | N | Dental Providers | Dentist | General Practice | 1223S0112X | D8635 | OR | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.