Provider Demographics
NPI:1164721510
Name:JAY ANDREW NELSON, D.M.D., P.A.
Entity Type:Organization
Organization Name:JAY ANDREW NELSON, D.M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-733-4169
Mailing Address - Street 1:26907 FOGGY CREEK RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6778
Mailing Address - Country:US
Mailing Address - Phone:813-733-4169
Mailing Address - Fax:888-977-1984
Practice Address - Street 1:26907 FOGGY CREEK RD STE 101
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6778
Practice Address - Country:US
Practice Address - Phone:813-733-4169
Practice Address - Fax:888-977-1984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10809122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6493070001Medicare NSC