Provider Demographics
NPI:1104972157
Name:WORTHY, T. PETER (DDS)
Entity type:Individual
Prefix:
First Name:T.
Middle Name:PETER
Last Name:WORTHY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 PROFESSIONAL PL
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3862
Mailing Address - Country:US
Mailing Address - Phone:777-832-1311
Mailing Address - Fax:770-836-0179
Practice Address - Street 1:103 PROFESSIONAL PL
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3862
Practice Address - Country:US
Practice Address - Phone:777-832-1311
Practice Address - Fax:770-836-0179
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0087361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice