Provider Demographics
NPI:1356793533
Name:SOUTHLAND CHILDREN'S DENTISTRY
Entity type:Organization
Organization Name:SOUTHLAND CHILDREN'S DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:STEVE
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-253-5888
Mailing Address - Street 1:2301 LULLWATER RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3180
Mailing Address - Country:US
Mailing Address - Phone:229-439-8896
Mailing Address - Fax:
Practice Address - Street 1:2301 LULLWATER RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3180
Practice Address - Country:US
Practice Address - Phone:229-439-8896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN15000261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental