Provider Demographics
NPI:1588715031
Name:SOUTHLAND DENTAL GROUP ANTOINE SOURIALLE DDS INC
Entity type:Organization
Organization Name:SOUTHLAND DENTAL GROUP ANTOINE SOURIALLE DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOINE
Authorized Official - Middle Name:O
Authorized Official - Last Name:SOURIALLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-881-0645
Mailing Address - Street 1:399 E HIGHLAND AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3808
Mailing Address - Country:US
Mailing Address - Phone:909-881-0645
Mailing Address - Fax:909-881-4957
Practice Address - Street 1:399 E HIGHLAND AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3808
Practice Address - Country:US
Practice Address - Phone:909-881-0645
Practice Address - Fax:909-881-4957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA440931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10490OtherPACIFICARE HMO
CA20088156OtherPREVIOUS EIN
CA004239OtherLIBERTY DENTAL HMO
CAB44093-01OtherDELTA HEALTHY FAMILY
CADJ61OtherSMILESAVER HMO
CAG92830-01OtherDENTI-CAL
CA007367OtherPMI HMO
CA50755-1OtherBLUE SHIELD
CA971330OtherUNITED CONCORDIA HMO
CA97036530OtherSAFEGUARD HMO
CA134921OtherDHS HMO
CAF0275OtherGOLDEN WEST HMO
CA0010973OtherASSURANT HMO
CAP006271OtherWELLPOINT HMO
CA0004636OtherMANAGED DENTAL HMO
CA01628OtherWESTERN DENTAL HMO
CA210745OtherCIGNA HMO