Provider Demographics
NPI:1336761097
Name:SOUTHERN OAK DENTAL, LLC
Entity Type:Organization
Organization Name:SOUTHERN OAK DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:GONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-371-2516
Mailing Address - Street 1:4921 CENTRE POINTE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-6997
Mailing Address - Country:US
Mailing Address - Phone:912-856-9698
Mailing Address - Fax:843-781-7403
Practice Address - Street 1:1322 BROAD ST UNIT 90
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1984
Practice Address - Country:US
Practice Address - Phone:912-856-9698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty