Provider Demographics
NPI:1053393694
Name:NELSON, GEORGE AUGUSTUS III (DMD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:AUGUSTUS
Last Name:NELSON
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4643 CAMP COLEMAN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-2821
Mailing Address - Country:US
Mailing Address - Phone:205-655-0603
Mailing Address - Fax:205-655-0693
Practice Address - Street 1:4643 CAMP COLEMAN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-2821
Practice Address - Country:US
Practice Address - Phone:205-655-0603
Practice Address - Fax:205-655-0693
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-94984OtherBCBS OF AL PROV. NUMBER
AL152289OtherUNITED CONCORDIA PROV #
AL630759179Medicare UPIN