Provider Demographics
NPI:1598332496
Name:SOUTHALL, PAYTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAYTON
Middle Name:
Last Name:SOUTHALL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:PAYTON
Other - Middle Name:
Other - Last Name:SOUTHALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:875 UNION AVE STE C211
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3513
Mailing Address - Country:US
Mailing Address - Phone:901-448-6240
Mailing Address - Fax:
Practice Address - Street 1:875 UNION AVE STE C211
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3513
Practice Address - Country:US
Practice Address - Phone:901-448-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4511122300000X
OH30.0266021223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice