Healthcare Provider Details

I. General information

NPI: 1952249195
Provider Name (Legal Business Name): SOUTHERN DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2026
Last Update Date: 03/21/2026
Certification Date: 03/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 W SOUTHERN AVE STE 111
PHOENIX AZ
85041-4307
US

IV. Provider business mailing address

3934 E AUSTIN DR
GILBERT AZ
85296-0711
US

V. Phone/Fax

Practice location:
  • Phone: 630-699-3744
  • Fax:
Mailing address:
  • Phone: 602-305-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: KENDRICK HOLYOAK
Title or Position: OWNER
Credential:
Phone: 630-699-3744