1588715031 NPI number — SOUTHLAND DENTAL GROUP ANTOINE SOURIALLE DDS INC

Table of content: (NPI 1588715031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588715031 NPI number — SOUTHLAND DENTAL GROUP ANTOINE SOURIALLE DDS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHLAND DENTAL GROUP ANTOINE SOURIALLE DDS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHLAND DENTAL GROUP ANTOINE SOURIALLE DDS
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588715031
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
399 E HIGHLAND AVE
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92404-3808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-881-0645
Provider Business Mailing Address Fax Number:
909-881-4957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
399 E HIGHLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92404-3808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-881-0645
Provider Business Practice Location Address Fax Number:
909-881-4957
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SOURIALLE
Authorized Official First Name:
ANTOINE
Authorized Official Middle Name:
O
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
909-881-0645

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  44093 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10490 . This is a "PACIFICARE HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 20088156 . This is a "PREVIOUS EIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 004239 . This is a "LIBERTY DENTAL HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: B44093-01 . This is a "DELTA HEALTHY FAMILY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: DJ61 . This is a "SMILESAVER HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G92830-01 . This is a "DENTI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 007367 . This is a "PMI HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 50755-1 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 971330 . This is a "UNITED CONCORDIA HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 97036530 . This is a "SAFEGUARD HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 134921 . This is a "DHS HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: F0275 . This is a "GOLDEN WEST HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0010973 . This is a "ASSURANT HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P006271 . This is a "WELLPOINT HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0004636 . This is a "MANAGED DENTAL HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 01628 . This is a "WESTERN DENTAL HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 210745 . This is a "CIGNA HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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