MEDICARE: DR. THERESA ADRIA WORSHAM DMD

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	1223P0300X	Periodontics	106218	CA

General Provider Information

NPI Number	:	1841772431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA ADRIA WORSHAM DMD

Provider Business Mailing Address
First Line	:	9309 OFFICE PARK CIR STE 120
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-8072
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9309 OFFICE PARK CIR STE 120
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-8072
Country	:	US
Telephone Number	:	916-236-3131
Fax Number	:

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

Provider Enumeration Date	:	08/30/2018
Last Update Date	:	09/15/2022

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