Provider Demographics
NPI:1366652174
Name:FREDRIC A MOORE DMD PC
Entity Type:Organization
Organization Name:FREDRIC A MOORE DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-456-2550
Mailing Address - Street 1:514 W BANKHEAD HWY
Mailing Address - Street 2:SUITE 600
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1736
Mailing Address - Country:US
Mailing Address - Phone:770-456-2550
Mailing Address - Fax:770-456-7680
Practice Address - Street 1:514 W BANKHEAD HWY
Practice Address - Street 2:SUITE 600
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1736
Practice Address - Country:US
Practice Address - Phone:770-456-2550
Practice Address - Fax:770-456-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA104141223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty