Provider Demographics
NPI:1629700992
Name:SOUTH, ANTHONY (DMD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:SOUTH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W JUNIPER AVE UNIT 1135
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-3973
Mailing Address - Country:US
Mailing Address - Phone:952-607-5292
Mailing Address - Fax:
Practice Address - Street 1:43522 HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-6812
Practice Address - Country:US
Practice Address - Phone:863-777-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011469122300000X
FLDN28727122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist