Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 22855 | TX |
Y | 1223E0200X | Endodontist | 22855 | TX |
NPI | 1164434742 |
---|---|
Provider Name | Dr. Justin Marcus Nelson |
First Address | Ft Eustis, VA 23604-5311 |
Second Address | Ft Eustis, VA 23604-5311 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2006 |
Last Update Date | 05/08/2011 |