Provider Demographics
NPI:1366103244
Name:SOUTHARD FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:SOUTHARD FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:ISRAELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:275-773-0432
Mailing Address - Street 1:6333 S MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-1948
Mailing Address - Country:US
Mailing Address - Phone:918-294-1144
Mailing Address - Fax:
Practice Address - Street 1:6333 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-1948
Practice Address - Country:US
Practice Address - Phone:918-294-1144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-04
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty