Provider Demographics
NPI:1689613788
Name:SOUTHALL, NICHOLAS LAMAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:LAMAR
Last Name:SOUTHALL
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 1:3263 DEMETROPOLIS RD
Mailing Address - Street 2:SUITE4
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-4638
Mailing Address - Country:US
Mailing Address - Phone:251-666-5113
Mailing Address - Fax:251-666-1484
Practice Address - Street 1:3263 DEMETROPOLIS RD
Practice Address - Street 2:SUITE4
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-4638
Practice Address - Country:US
Practice Address - Phone:251-666-5113
Practice Address - Fax:251-666-1484
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice