Provider Demographics
NPI:1952782625
Name:NELSON, BROOKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5707 ARCHTREE PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2218
Mailing Address - Country:US
Mailing Address - Phone:502-931-9051
Mailing Address - Fax:
Practice Address - Street 1:6810 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-3914
Practice Address - Country:US
Practice Address - Phone:502-873-0171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9603122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist