=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699353169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE MARIE DESHON NELSON DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2021
-----------------------------------------------------
Last Update Date | 03/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 CLEVELAND AVE STE E
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24112-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-638-8888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 CLEVELAND AVE STE E
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24112-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-638-8888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 0401414265
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------