MEDICARE: FRED F WORRALL, DDS, PC

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	1223G0001X	General Practice Dentistry	011402	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN011402	OTHER	GA	GA BOARD OF DENTISTRY LIC

General Provider Information

NPI Number	:	1861514507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRED F WORRALL, DDS, PC

Provider Business Mailing Address
First Line	:	707 WHITLOCK AVE SW STE D29
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-3083
Country	:	US
Telephone Number	:	770-792-2300
Fax Number	:	770-792-2436

Provider Business Practice Location Address
First Line	:	707 WHITLOCK AVE SW STE D29
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-3083
Country	:	US
Telephone Number	:	770-792-2300
Fax Number	:	770-792-2436

Authorized Official
Title or Position	:	OWNER
Name	:	DR. FRED FRANCIS WORRALL II
Credential	:	DDS
Telephone Number	:	770-792-2300

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	08/22/2020

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