Provider Demographics
NPI:1487658134
Name:SOUTHERLAND, GARY BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:BRIAN
Last Name:SOUTHERLAND
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 1:1910 BIRDCREEK DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-1001
Mailing Address - Country:US
Mailing Address - Phone:254-773-6373
Mailing Address - Fax:254-773-6582
Practice Address - Street 1:1910 BIRDCREEK DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1001
Practice Address - Country:US
Practice Address - Phone:254-773-6373
Practice Address - Fax:254-773-6582
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15454122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist