Healthcare Provider Details

I. General information

NPI: 1073444287
Provider Name (Legal Business Name): SOUTHSIDE DENTAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 E BAY DR
LARGO FL
33771-2218
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 204
ST AUGUSTINE FL
32080-3111
US

V. Phone/Fax

Practice location:
  • Phone: 727-535-6400
  • Fax:
Mailing address:
  • Phone: 904-794-1824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN STROUT
Title or Position: OWNER
Credential: DMD, MS, PA
Phone: 904-794-1824