=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164721510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAY ANDREW NELSON, D.M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2011
-----------------------------------------------------
Last Update Date | 08/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26907 FOGGY CREEK RD STE 101
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544-6778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-733-4169
-----------------------------------------------------
Fax | 888-977-1984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26907 FOGGY CREEK RD STE 101
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544-6778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-733-4169
-----------------------------------------------------
Fax | 888-977-1984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAY A NELSON
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 813-733-4169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN10809
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------