Healthcare Provider Details

I. General information

NPI: 1821141870
Provider Name (Legal Business Name): GREGG R CODELLI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707A MOUNT VERNON RD
ATLANTA GA
30338-4207
US

IV. Provider business mailing address

3941 GLENNCREST CT NE
ATLANTA GA
30319-1893
US

V. Phone/Fax

Practice location:
  • Phone: 770-668-0604
  • Fax: 770-234-4065
Mailing address:
  • Phone: 770-668-0604
  • Fax: 770-234-4065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number10306
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: