Provider Demographics
NPI:1700987732
Name:SOUTHERN DENTAL ASSOCIATES, P.A.
Entity type:Organization
Organization Name:SOUTHERN DENTAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST SECRETARY OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:ELLISON
Authorized Official - Last Name:TRAMMELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-477-5252
Mailing Address - Street 1:151 W AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505
Mailing Address - Country:US
Mailing Address - Phone:850-477-5252
Mailing Address - Fax:850-477-5532
Practice Address - Street 1:151 W AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505
Practice Address - Country:US
Practice Address - Phone:850-477-5252
Practice Address - Fax:850-477-5532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty