Healthcare Provider Details

I. General information

NPI: 1730461492
Provider Name (Legal Business Name): CHARLES EDWARD GREGORY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 PEACHTREE DUNWOODY RD NE SUITE 275
ATLANTA GA
30342-1703
US

IV. Provider business mailing address

5555 PEACHTREE DUNWOODY RD NE SUITE 275
ATLANTA GA
30342-1703
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-4772
  • Fax: 404-843-1743
Mailing address:
  • Phone: 404-256-4772
  • Fax: 404-843-1743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7172
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: