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General NPI Number Information
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NPI Number | 1952249195
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Entity Type | Organization
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Legal Business Name | SOUTHERN DENTAL LLC
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Dates
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Enumeration Date | 03/21/2026
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Last Update Date | 03/21/2026
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Provider Practice Location Address
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Address Line | 3320 W SOUTHERN AVE STE 111
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City | PHOENIX
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State | AZ
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Zip | 85041-4307
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Country | US
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Telephone | 630-699-3744
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Fax |
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Provider Business Mailing Address
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Address Line | 3934 E AUSTIN DR
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City | GILBERT
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State | AZ
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Zip | 85296-0711
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Country | US
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Telephone | 602-305-8800
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KENDRICK HOLYOAK
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Credential |
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Telephone | 630-699-3744
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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