Provider Demographics
NPI:1346583457
Name:SOUTHSIDE FAMILY & COSMETIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:SOUTHSIDE FAMILY & COSMETIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-442-1463
Mailing Address - Street 1:1745 HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:SOUTHSIDE
Mailing Address - State:AL
Mailing Address - Zip Code:35907-0169
Mailing Address - Country:US
Mailing Address - Phone:256-442-1463
Mailing Address - Fax:256-442-9821
Practice Address - Street 1:1745 HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:SOUTHSIDE
Practice Address - State:AL
Practice Address - Zip Code:35907-0169
Practice Address - Country:US
Practice Address - Phone:256-442-1463
Practice Address - Fax:256-442-9821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty