Antoine O. Sourialle, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

44093 Issued in CA

Practice address

399 E Highland Ave Ste 120
San Bernardino, CA 92404-3812

Phone

(909) 881-0645

Fax

(909) 881-4957

NPI assigned

Mar 30, 2007

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 15

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Southland Dental Group Antoine Sourialle DDS Inc

  • General Practice Dentistry
  • San Bernardino, CA
  • NPI 1588715031
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175212800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1811017031",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "399 E HIGHLAND AVE STE 120",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "924043812",
            "telephone_number": "909-881-0645",
            "fax_number": "909-881-4957"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "399 E HIGHLAND AVE STE 120",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "924043812",
            "telephone_number": "909-881-0645",
            "fax_number": "909-881-4957"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SOURIALLE",
        "first_name": "ANTOINE",
        "middle_name": "O.",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-03-30",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CA",
            "license": "44093",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ASSURANT HMO",
            "identifier": "0010973",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CIGNA HMO",
            "identifier": "0210745",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PACIFICARE",
            "identifier": "10490",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WELLPOINT DENTAL",
            "identifier": "P006271",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WESTERN DENTAL",
            "identifier": "01628",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "50755-1",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LIBERTY DENTAL HMO",
            "identifier": "004239",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MANAGED DENTAL CARE",
            "identifier": "0004636",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SMILESAVER",
            "identifier": "DJ61",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRIVIOUS EIN",
            "identifier": "20088156",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PMI",
            "identifier": "007367",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DHS HMO",
            "identifier": "134921",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SAFEGUARD HMO",
            "identifier": "97036530",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENT-CAL",
            "identifier": "D44093",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GOLDENWEST",
            "identifier": "F0275",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Marisela Soto
• Ryan Soto, CRNA
• Vanessa Soto
• Victoria Christina Soto
• Sound Mind Counseling and Consulting, a Professional Licensed Clinical Social Worker Corporation
• Sarah Sourialle, DMD
• Larry E Southard, MA MFT
• Southern California Emergency Medicine
• Southland Anesthesia Consultants Inc
• Southland Cardiology Medical Group

• General Practice Dentistry in San Bernardino, CA
• Providers in San Bernardino, CA by specialty
• General Practice Dentistry in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.