MEDICARE: SOUTHERN DENTAL LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1223D0001X	Public Health Dentistry
2	1223E0200X	Endodontics
3	1223G0001X	General Practice Dentistry
4	1223P0221X	Pediatric Dentistry
5	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
6	122300000X	Dentist

General Provider Information

NPI Number	:	1952249195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN DENTAL LLC

Provider Business Mailing Address
First Line	:	3934 E AUSTIN DR
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-0711
Country	:	US
Telephone Number	:	602-305-8800
Fax Number	:

Provider Business Practice Location Address
First Line	:	3320 W SOUTHERN AVE STE 111
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-4307
Country	:	US
Telephone Number	:	630-699-3744
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KENDRICK HOLYOAK
Credential	:
Telephone Number	:	630-699-3744

Provider Enumeration Date	:	03/21/2026
Last Update Date	:	03/21/2026

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Directions to “SOUTHERN DENTAL LLC ” Practice Location

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