Provider Demographics
NPI:1912092651
Name:SOUTHFIELD FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:SOUTHFIELD FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:SHERIDAN
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-868-5115
Mailing Address - Street 1:230 CARROLL ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4248
Mailing Address - Country:US
Mailing Address - Phone:318-868-5115
Mailing Address - Fax:318-868-5114
Practice Address - Street 1:230 CARROLL ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4248
Practice Address - Country:US
Practice Address - Phone:318-868-5115
Practice Address - Fax:318-868-5114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty