=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366733644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROADWAY FAMILY AND COSMETIC DENTISTRY PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2011
-----------------------------------------------------
Last Update Date | 04/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 556 N BROADWAY
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40508-1761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-253-3242
-----------------------------------------------------
Fax | 859-253-0025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 556 N BROADWAY
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40508-1761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-253-3242
-----------------------------------------------------
Fax | 859-253-0025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. APRILLE RASHEDA NELSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 859-253-3242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 8731
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------