Provider Demographics
NPI:1265616213
Name:SOUTHERN DENTAL
Entity type:Organization
Organization Name:SOUTHERN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:P
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-305-8800
Mailing Address - Street 1:3320 W. SOUTHERN AVENUE
Mailing Address - Street 2:SUITE # 108
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041
Mailing Address - Country:US
Mailing Address - Phone:602-305-8800
Mailing Address - Fax:602-305-8801
Practice Address - Street 1:3320 W. SOUTHERN AVENUE
Practice Address - Street 2:SUITE # 108
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041
Practice Address - Country:US
Practice Address - Phone:602-305-8800
Practice Address - Fax:602-305-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5995122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty