Provider Demographics
NPI:1033963020
Name:PAYTON SOUTHALL, DDS, PLLC
Entity Type:Organization
Organization Name:PAYTON SOUTHALL, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAYTON
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-252-0472
Mailing Address - Street 1:323 SHAWNEE CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOPE
Mailing Address - State:WV
Mailing Address - Zip Code:25880-8988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 RAGLAND RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-9721
Practice Address - Country:US
Practice Address - Phone:304-252-0472
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-15
Last Update Date:2024-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty