Provider Demographics
NPI:1154859320
Name:SOUTHERN ROOTS DENTISTRY LLC
Entity Type:Organization
Organization Name:SOUTHERN ROOTS DENTISTRY LLC
Other - Org Name:SOUTHERN ROOTS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-701-8885
Mailing Address - Street 1:8691 LINE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6107
Mailing Address - Country:US
Mailing Address - Phone:318-701-8885
Mailing Address - Fax:318-701-8887
Practice Address - Street 1:8691 LINE AVE STE 300
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-701-8885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA67471223G0001X
LA67501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty