Provider Demographics
NPI:1306340849
Name:SOUTHHOUSE DENTAL, LLC
Entity type:Organization
Organization Name:SOUTHHOUSE DENTAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SORHUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-781-7509
Mailing Address - Street 1:120 TRADING BAY RD STE 280
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7781
Mailing Address - Country:US
Mailing Address - Phone:907-335-0363
Mailing Address - Fax:907-335-0364
Practice Address - Street 1:36892 MALLARD RD
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-6434
Practice Address - Country:US
Practice Address - Phone:900-728-3921
Practice Address - Fax:907-283-3184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1380261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental