Provider Demographics
NPI:1487670667
Name:SOUTHLAKE FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:SOUTHLAKE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:KIMSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,FAGD
Authorized Official - Phone:803-548-3342
Mailing Address - Street 1:1741 GOLD HILL RD
Mailing Address - Street 2:SUITE 2010
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8202
Mailing Address - Country:US
Mailing Address - Phone:803-548-3342
Mailing Address - Fax:803-548-3817
Practice Address - Street 1:1741 GOLD HILL RD
Practice Address - Street 2:SUITE 2010
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8202
Practice Address - Country:US
Practice Address - Phone:803-548-3342
Practice Address - Fax:803-548-3817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35491223G0001X
SC25881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty