MEDICARE: DR. GREGG R CODELLI D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	10306	GA

General Provider Information

NPI Number	:	1821141870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGG R CODELLI D.D.S.

Provider Business Mailing Address
First Line	:	3941 GLENNCREST CT NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30319-1893
Country	:	US
Telephone Number	:	770-668-0604
Fax Number	:	770-234-4065

Provider Business Practice Location Address
First Line	:	1707A MOUNT VERNON RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30338-4207
Country	:	US
Telephone Number	:	770-668-0604
Fax Number	:	770-234-4065

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2007
Last Update Date	:	07/08/2007

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