1588715031 NPI number — SOUTHLAND DENTAL GROUP ANTOINE SOURIALLE DDS INC

Table of Contents

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:
Provider Other Organization Name Type Code:
6
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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