Healthcare Provider Details

I. General information

NPI: 1780505792
Provider Name (Legal Business Name): SOUTHLAND CHILDRENS DENTISTRY BAINBRIDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 E SHOTWELL ST.
BAINBRIDGE GA
39819-4255
US

IV. Provider business mailing address

1503 E SHOTWELL ST.
BAINBRIDGE GA
39819-4255
US

V. Phone/Fax

Practice location:
  • Phone: 229-246-6372
  • Fax: 260-529-7745
Mailing address:
  • Phone: 229-246-6372
  • Fax: 260-529-7745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KENNETH S SELLERS JR.
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 229-246-6372