Provider Demographics
NPI:1780385021
Name:SOUTHERN SMILES DENTAL GROUP LLC
Entity type:Organization
Organization Name:SOUTHERN SMILES DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNIE
Authorized Official - Suffix:III
Authorized Official - Credentials:MBA
Authorized Official - Phone:334-661-7671
Mailing Address - Street 1:302 ROYAL PKWY
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-6944
Mailing Address - Country:US
Mailing Address - Phone:334-661-7671
Mailing Address - Fax:
Practice Address - Street 1:2001 ALEXANDER DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3003
Practice Address - Country:US
Practice Address - Phone:334-794-0348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental