Provider Demographics
NPI:1336284025
Name:SOUTHERN DENTAL
Entity Type:Organization
Organization Name:SOUTHERN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SUN
Authorized Official - Middle Name:
Authorized Official - Last Name:HWANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-439-2988
Mailing Address - Street 1:9920 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-8333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9920 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-8333
Practice Address - Country:US
Practice Address - Phone:718-439-2988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048586122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty