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Organization
SOUTHLAND DENTAL GROUP ANTOINE SOURIALLE DDS INC
Active
Organization
SOUTHLAND DENTAL GROUP ANTOINE SOURIALLE DDS INC
Active
Other names
Southland Dental Group Antoine Sourialle DDS
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ANTOINE O SOURIALLE DDS (OWNER)
(909) 881-0645
Entity
Organization
Contact information
Practice address
399 E HIGHLAND AVE, SUITE 120, SAN BERNARDINO, CA 92404-3808
(909) 881-0645
(909) 881-4957
Mailing address
399 E HIGHLAND AVE, SUITE 120, SAN BERNARDINO, CA 92404-3808
(909) 881-0645
(909) 881-4957
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
44093
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0004636
MANAGED DENTAL HMO
CA
01
—
0010973
ASSURANT HMO
CA
01
—
004239
LIBERTY DENTAL HMO
CA
01
—
007367
PMI HMO
CA
01
—
01628
WESTERN DENTAL HMO
CA
01
—
10490
PACIFICARE HMO
CA
01
—
134921
DHS HMO
CA
01
—
20088156
PREVIOUS EIN
CA
01
—
210745
CIGNA HMO
CA
01
—
50755-1
BLUE SHIELD
CA
01
—
97036530
SAFEGUARD HMO
CA
01
—
971330
UNITED CONCORDIA HMO
CA
01
—
B44093-01
DELTA HEALTHY FAMILY
CA
01
—
DJ61
SMILESAVER HMO
CA
01
—
F0275
GOLDEN WEST HMO
CA
01
—
G92830-01
DENTI-CAL
CA
01
—
P006271
WELLPOINT HMO
CA
Enumeration date
01/12/2007
Last updated
08/22/2020
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