SOUTHSIDE FAMILY & COSMETIC DENTISTRY, LLC

Contacts

Phone	+1 256-442-1463
Fax	2564429821

Authorized person

Name	DONNA JENNINGS
Role	OFFICE MANAGER
Phone	2564421463

Taxonomy

Taxonomy Code	1223G0001X - General Practice Dentistry
Is Primary	Yes
Taxonomy Code	124Q00000X - Dental Hygienist
Is Primary	No
Taxonomy Code	126800000X - Dental Assistant
Is Primary	No

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2013-04-01
Business code	621210
Sponsor’s telephone number	2564421463
Plan sponsor’s address	715 WALNUT ST, FL 2, SECOND FLOOR, GADSDEN, AL, 359014138

Signature of

Role	Plan administrator
Date	2023-10-25
Name of individual signing	JEFFREY W. TAYLOR

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2013-04-01
Business code	621210
Sponsor’s telephone number	2564421463
Plan sponsor’s address	715 WALNUT ST FL 2, GADSDEN, AL, 35901

Signature of

Role	Plan administrator
Date	2022-10-24
Name of individual signing	RICKEY HESS
Role	Employer/plan sponsor
Date	2022-10-24
Name of individual signing	RICKEY HESS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2013-04-01
Business code	621210
Sponsor’s telephone number	2564421463
Plan sponsor’s address	715 WALNUT ST FL 2, GADSDEN, AL, 35901

Signature of

Role	Plan administrator
Date	2021-10-18
Name of individual signing	RICKEY HESS
Role	Employer/plan sponsor
Date	2021-10-18
Name of individual signing	RICKEY HESS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2013-04-01
Business code	621210
Sponsor’s telephone number	2564421463
Plan sponsor’s address	715 WALNUT ST FL 2, GADSDEN, AL, 35901

Signature of

Role	Plan administrator
Date	2020-12-09
Name of individual signing	RICKEY HESS
Role	Employer/plan sponsor
Date	2020-12-09
Name of individual signing	RICKEY HESS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2013-04-01
Business code	621210
Sponsor’s telephone number	2564421463
Plan sponsor’s address	715 WALNUT ST, FL 2, SECOND FLOOR, GADSDEN, AL, 359014138

Signature of

Role	Plan administrator
Date	2019-11-05
Name of individual signing	RICKEY D. HESS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2013-04-01
Business code	621210
Sponsor’s telephone number	2564421463
Plan sponsor’s address	715 WALNUT ST, FL 2, SECOND FLOOR, GADSDEN, AL, 359014138

Signature of

Role	Plan administrator
Date	2018-11-06
Name of individual signing	RICKEY D. HESS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2013-04-01
Business code	621210
Sponsor’s telephone number	2564421463
Plan sponsor’s address	715 WALNUT ST, FL 2, SECOND FLOOR, GADSDEN, AL, 359014138

Signature of

Role	Plan administrator
Date	2017-10-30
Name of individual signing	RICKEY D. HESS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2013-04-01
Business code	621210
Sponsor’s telephone number	2564421463
Plan sponsor’s address	200 BROAD STREET, 3RD FLR, SUITE B, GADSDEN, AL, 359013714

Signature of

Role	Plan administrator
Date	2016-11-09
Name of individual signing	RICKEY D. HESS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2013-04-01
Business code	621210
Sponsor’s telephone number	2564421463
Plan sponsor’s address	200 BROAD STREET, 3RD FLR, SUITE B, GADSDEN, AL, 359013714

Signature of

Role	Plan administrator
Date	2015-10-06
Name of individual signing	RICKEY D. HESS

Three-digit plan number (PN)	001
Effective date of plan	2013-04-01
Business code	621210
Sponsor’s telephone number	2564421463
Plan sponsor’s address	200 BROAD STREET, 3RD FLR, SUITE B, GADSDEN, AL, 359013714

Signature of

Role	Plan administrator
Date	2014-02-13
Name of individual signing	RICKEY D. HESS