Provider Demographics
NPI:1922422435
Name:SOUTHERN DENTAL LLC
Entity Type:Organization
Organization Name:SOUTHERN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:302-999-7600
Mailing Address - Street 1:703 HEALTH SERVICES DR
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-5784
Mailing Address - Country:US
Mailing Address - Phone:302-999-7600
Mailing Address - Fax:302-998-6704
Practice Address - Street 1:703 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-5784
Practice Address - Country:US
Practice Address - Phone:302-999-7600
Practice Address - Fax:302-998-6704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00010401223G0001X
DEG1-00012161223G0001X
DEG1-00010111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty