Provider Demographics
NPI:1396835732
Name:SOUTHERN VIEW DENTAL GROUP
Entity Type:Organization
Organization Name:SOUTHERN VIEW DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IBRAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSOUD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-522-4121
Mailing Address - Street 1:2743 S 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703
Mailing Address - Country:US
Mailing Address - Phone:217-522-4121
Mailing Address - Fax:217-522-7140
Practice Address - Street 1:2743 S 6TH STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703
Practice Address - Country:US
Practice Address - Phone:217-522-4121
Practice Address - Fax:217-522-7140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty