Basic Information
| Provider Information | |||||||||
| NPI: | 1982907689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | JAZMIN | ||||||||
| MiddleName: | SOPHIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIVERS | ||||||||
| OtherFirstName: | JAZMIN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 401 RAILROAD ST W | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062584789 | ||||||||
| FaxNumber: | 4062584732 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 RAILROAD ST W | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062584789 | ||||||||
| FaxNumber: | 4062584732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2010 | ||||||||
| LastUpdateDate: | 05/05/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D9545 | OR | N | Dental Providers | Dentist | 122300000X | DEN-DEN-LIC-5964 | MT | Y | Dental Providers | Dentist |
No ID Information.