Provider Demographics
NPI:1821141870
Name:CODELLI, GREGG R (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:R
Last Name:CODELLI
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 1:3941 GLENNCREST CT NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1893
Mailing Address - Country:US
Mailing Address - Phone:770-668-0604
Mailing Address - Fax:770-234-4065
Practice Address - Street 1:1707A MOUNT VERNON RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-4207
Practice Address - Country:US
Practice Address - Phone:770-668-0604
Practice Address - Fax:770-234-4065
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103061223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics