=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801028592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LORI D. NELSON DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2009
-----------------------------------------------------
Last Update Date | 08/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 730 EMERSON DR. NW
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-984-7878
-----------------------------------------------------
Fax | 321-953-0279
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 730 EMERSON DR. NW
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-984-7878
-----------------------------------------------------
Fax | 321-953-0279
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASSISTANT
-----------------------------------------------------
Name | MICHELE ELIZABETH MILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-984-7878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 10353
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------