Provider Demographics
NPI:1134163785
Name:DALEY, PATRICK BRIAN
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:BRIAN
Last Name:DALEY
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 1:100 HUNTER VILLAGE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063
Mailing Address - Country:US
Mailing Address - Phone:803-407-9580
Mailing Address - Fax:803-407-9579
Practice Address - Street 1:100 HUNTER VILLAGE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063
Practice Address - Country:US
Practice Address - Phone:803-407-9580
Practice Address - Fax:803-407-9579
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC-3522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9841Medicaid