Provider Demographics
NPI:1467672410
Name:BOOTH, BRIAN GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GREGORY
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9590 MEDLOCK BRIDGE RD
Mailing Address - Street 2:STE B
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5990
Mailing Address - Country:US
Mailing Address - Phone:770-623-1427
Mailing Address - Fax:770-623-1845
Practice Address - Street 1:9590 MEDLOCK BRIDGE RD
Practice Address - Street 2:STE B
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-5990
Practice Address - Country:US
Practice Address - Phone:770-623-1427
Practice Address - Fax:770-623-1845
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist