Provider Demographics
NPI:1164526570
Name:TODD SOUTHALL DDS PLLC
Entity Type:Organization
Organization Name:TODD SOUTHALL DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:D
Authorized Official - Last Name:SOUTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-404-8393
Mailing Address - Street 1:11381 N SCIOTO AVE
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-7212
Mailing Address - Country:US
Mailing Address - Phone:520-404-8393
Mailing Address - Fax:
Practice Address - Street 1:11381 N SCIOTO AVE
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85737-7212
Practice Address - Country:US
Practice Address - Phone:520-404-8393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD7787122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty