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General NPI Number Information
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NPI Number | 1225527914
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Entity Type | Individual
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Provider Name | JEVAE LENIECE NELSON DDS, DMSC
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Gender | Female
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Dates
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Enumeration Date | 05/08/2018
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Last Update Date | 02/03/2022
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Provider Practice Location Address
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Address Line | 4070 LAVISTA RD UNIT 102
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City | TUCKER
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State | GA
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Zip | 30084-5228
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Country | US
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Telephone | 770-515-8532
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Fax |
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Provider Business Mailing Address
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Address Line | 2554 SIBLEY DR NE
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City | ATLANTA
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State | GA
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Zip | 30324-3104
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Country | US
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Telephone | 816-304-0482
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN122573
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN1857897
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License Number State | MA
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