Healthcare Provider Details

I. General information

NPI: 1366652174
Provider Name (Legal Business Name): FREDRIC A MOORE DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 W BANKHEAD HWY SUITE 600
VILLA RICA GA
30180-1736
US

IV. Provider business mailing address

514 W BANKHEAD HWY SUITE 600
VILLA RICA GA
30180-1736
US

V. Phone/Fax

Practice location:
  • Phone: 770-456-2550
  • Fax: 770-456-7680
Mailing address:
  • Phone: 770-456-2550
  • Fax: 770-456-7680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number10414
License Number StateGA

VIII. Authorized Official

Name: DR. FREDRIC A MOORE
Title or Position: PRESIDENT
Credential: DMD
Phone: 770-456-2550