# SOUTHARD FAMILY DENTAL, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1366103244
- **Authorized official:** LOREN PAUL ISRAELSEN DDS (CEO)
- **Authorized official phone:** (275) 773-0432

## Contact information

- **Practice address:** 6333 S MEMORIAL DR, TULSA, OK 74133-1948
- **Practice address phone:** (918) 294-1144
- **Mailing address:** 6333 S MEMORIAL DR, TULSA, OK 74133-1948
- **Mailing address phone:** (918) 294-1144

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | — | — | Yes |

## Other

- **Enumeration date:** 01/04/2022
- **Last updated:** 09/06/2023