Provider Demographics
NPI:1811017031
Name:SOURIALLE, ANTOINE O (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANTOINE
Middle Name:O
Last Name:SOURIALLE
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 1:399 E HIGHLAND AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3812
Mailing Address - Country:US
Mailing Address - Phone:909-881-0645
Mailing Address - Fax:909-881-4957
Practice Address - Street 1:399 E HIGHLAND AVE STE 120
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3812
Practice Address - Country:US
Practice Address - Phone:909-881-0645
Practice Address - Fax:909-881-4957
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA440931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0010973OtherASSURANT HMO
CA0210745OtherCIGNA HMO
CA10490OtherPACIFICARE
CAP006271OtherWELLPOINT DENTAL
CA01628OtherWESTERN DENTAL
CA50755-1OtherBLUE SHIELD
CA004239OtherLIBERTY DENTAL HMO
CA0004636OtherMANAGED DENTAL CARE
CADJ61OtherSMILESAVER
CA20088156OtherPRIVIOUS EIN
CA007367OtherPMI
CA134921OtherDHS HMO
CA97036530OtherSAFEGUARD HMO
CAD44093OtherDENT-CAL
CAF0275OtherGOLDENWEST