Provider Demographics
NPI:1225527914
Name:NELSON, JEVAE LENIECE (DDS, DMSC)
Entity Type:Individual
Prefix:DR
First Name:JEVAE
Middle Name:LENIECE
Last Name:NELSON
Suffix:
Gender:F
Credentials:DDS, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2554 SIBLEY DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3104
Mailing Address - Country:US
Mailing Address - Phone:816-304-0482
Mailing Address - Fax:
Practice Address - Street 1:4070 LAVISTA RD UNIT 102
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5228
Practice Address - Country:US
Practice Address - Phone:770-515-8532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122573122300000X
MADN18578971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice