Provider Demographics
NPI:1275531964
Name:SALLEY, ELIZABETH LYNETT (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:LYNETT
Last Name:SALLEY
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 1:2887 FLORENCE DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30504-5675
Mailing Address - Country:US
Mailing Address - Phone:770-718-1829
Mailing Address - Fax:
Practice Address - Street 1:715 QUEEN CITY PKWY
Practice Address - Street 2:STE 101
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-4358
Practice Address - Country:US
Practice Address - Phone:770-297-8900
Practice Address - Fax:770-297-8992
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010057122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00333165HMedicaid