MEDICARE: DR. GEORGE WALLACE SORRELLS III D.D.S.

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	2948	AR

General Provider Information

NPI Number	:	1649391830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE WALLACE SORRELLS III D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 175
Second Line	:
City	:	WEST MEMPHIS
State	:	AR
Zip	:	72303-0175
Country	:	US
Telephone Number	:	870-732-5100
Fax Number	:

Provider Business Practice Location Address
First Line	:	623 N MISSOURI ST
Second Line	:
City	:	WEST MEMPHIS
State	:	AR
Zip	:	72301-3115
Country	:	US
Telephone Number	:	870-732-5100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	07/08/2007

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