Provider Demographics
NPI:1659562098
Name:SOUTHLAND DENTAL CARE
Entity Type:Organization
Organization Name:SOUTHLAND DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTICS
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HANOOKAI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:818-788-8787
Mailing Address - Street 1:4312 WOODMAN AVE
Mailing Address - Street 2:SUITE #100
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-5546
Mailing Address - Country:US
Mailing Address - Phone:818-788-8787
Mailing Address - Fax:818-788-4858
Practice Address - Street 1:4312 WOODMAN AVE
Practice Address - Street 2:SUITE #100
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-5546
Practice Address - Country:US
Practice Address - Phone:818-788-8787
Practice Address - Fax:818-788-4858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA530491223G0001X
CA419191223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty