Healthcare Provider Details

I. General information

NPI: 1497887491
Provider Name (Legal Business Name): MICHAEL EVERETTE SALLEY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 BENNETT ST
ORANGEBURG SC
29115-4214
US

IV. Provider business mailing address

924 BENNETT ST
ORANGEBURG SC
29115-4214
US

V. Phone/Fax

Practice location:
  • Phone: 803-534-2931
  • Fax: 803-534-3124
Mailing address:
  • Phone: 803-534-2931
  • Fax: 803-534-3124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2887
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: