MEDICARE: DR. GARY BRIAN SOUTHERLAND DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	15454	TX

General Provider Information

NPI Number	:	1487658134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY BRIAN SOUTHERLAND DDS

Provider Business Mailing Address
First Line	:	1910 BIRDCREEK DR
Second Line	:
City	:	TEMPLE
State	:	TX
Zip	:	76502-1001
Country	:	US
Telephone Number	:	254-773-6373
Fax Number	:	254-773-6582

Provider Business Practice Location Address
First Line	:	1910 BIRDCREEK DR
Second Line	:
City	:	TEMPLE
State	:	TX
Zip	:	76502-1001
Country	:	US
Telephone Number	:	254-773-6373
Fax Number	:	254-773-6582

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	07/08/2007

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