MEDICARE: DR. LEZLIE ANN NELSON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D10713	MN

General Provider Information

NPI Number	:	1699825612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEZLIE ANN NELSON D.D.S.

Provider Business Mailing Address
First Line	:	1320 NILES AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-1631
Country	:	US
Telephone Number	:	651-222-0983
Fax Number	:

Provider Business Practice Location Address
First Line	:	375 JACKSON ST STE 200
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55101-1806
Country	:	US
Telephone Number	:	651-222-0983
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/08/2007

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