Provider Demographics
NPI:1427510767
Name:SOUTHERN OAK DENTAL, LLC
Entity type:Organization
Organization Name:SOUTHERN OAK DENTAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:GONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-371-2940
Mailing Address - Street 1:4921 CENTRE POINTE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-6997
Mailing Address - Country:US
Mailing Address - Phone:843-459-8780
Mailing Address - Fax:
Practice Address - Street 1:2127 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1454
Practice Address - Country:US
Practice Address - Phone:864-216-7390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-04
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty