Provider Demographics
NPI:1720114341
Name:YOUNGBLOOD, GREGG CANDLER (DMD)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:CANDLER
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 S PEACHTREE ST
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-2503
Mailing Address - Country:US
Mailing Address - Phone:770-448-3552
Mailing Address - Fax:770-448-3552
Practice Address - Street 1:51 S PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-2503
Practice Address - Country:US
Practice Address - Phone:770-448-3552
Practice Address - Fax:770-448-3552
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0100721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice