Provider Demographics
NPI:1043958671
Name:SCALF, BRYAN EDWARD
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:EDWARD
Last Name:SCALF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 MACLAND RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-5134
Mailing Address - Country:US
Mailing Address - Phone:704-451-0817
Mailing Address - Fax:
Practice Address - Street 1:2176 MACLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-5134
Practice Address - Country:US
Practice Address - Phone:704-451-0817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN123044122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program