1275531964 NPI number — DR. ELIZABETH LYNETT SALLEY DMD

Table of content: ASHLEY CARR M.A., LPC (NPI 1427596519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275531964 NPI number — DR. ELIZABETH LYNETT SALLEY DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SALLEY
Provider First Name:
ELIZABETH
Provider Middle Name:
LYNETT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275531964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2887 FLORENCE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30504-5675
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-718-1829
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 QUEEN CITY PKWY
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-4358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-297-8900
Provider Business Practice Location Address Fax Number:
770-297-8992
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  010057 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00333165H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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