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General NPI Number Information
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NPI Number | 1306340849
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Entity Type | Organization
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Legal Business Name | SOUTHHOUSE DENTAL, LLC
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Dates
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Enumeration Date | 03/20/2018
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Last Update Date | 03/20/2018
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Provider Practice Location Address
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Address Line | 36892 MALLARD RD
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City | KENAI
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State | AK
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Zip | 99611-6434
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Country | US
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Telephone | 900-728-3921
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Fax | 907-283-3184
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Provider Business Mailing Address
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Address Line | 120 TRADING BAY RD STE 280
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City | KENAI
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State | AK
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Zip | 99611-7781
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Country | US
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Telephone | 907-335-0363
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Fax | 907-335-0364
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. JEREMY SCOTT SORHUS
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Credential | DDS
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Telephone | 406-781-7509
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 1380
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License Number State | AK
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