=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366652174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDRIC A MOORE DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 01/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 514 W BANKHEAD HWY SUITE 600
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-1736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-456-2550
-----------------------------------------------------
Fax | 770-456-7680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 514 W BANKHEAD HWY SUITE 600
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-1736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-456-2550
-----------------------------------------------------
Fax | 770-456-7680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. FREDRIC A MOORE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 770-456-2550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 10414
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------