Provider Demographics
NPI:1710961198
Name:SALL, EDWARD TRACY (MD,DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:TRACY
Last Name:SALL
Suffix:
Gender:M
Credentials:MD,DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5471 KEARNY VILLA RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1143
Mailing Address - Country:US
Mailing Address - Phone:866-801-9440
Mailing Address - Fax:
Practice Address - Street 1:4000 MEDICAL CENTER DR.
Practice Address - Street 2:STE 404
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066
Practice Address - Country:US
Practice Address - Phone:315-234-9865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1045531223X0400X
NY181365207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU10859Medicare UPIN
NY55304BMedicare ID - Type Unspecified