Healthcare Provider Details

I. General information

NPI: 1275531964
Provider Name (Legal Business Name): ELIZABETH LYNETT SALLEY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 QUEEN CITY PKWY STE 101
GAINESVILLE GA
30501-4358
US

IV. Provider business mailing address

2887 FLORENCE DR
GAINESVILLE GA
30504-5675
US

V. Phone/Fax

Practice location:
  • Phone: 770-297-8900
  • Fax: 770-297-8992
Mailing address:
  • Phone: 770-718-1829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number010057
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: