Provider Demographics
NPI:1295715274
Name:SOUTHWELL, ANGELA WILBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:WILBERT
Last Name:SOUTHWELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:IDELLE
Other - Last Name:WILBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:105 DANWOOD CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-6311
Mailing Address - Country:US
Mailing Address - Phone:910-603-1090
Mailing Address - Fax:
Practice Address - Street 1:206 RIVERGATE PKWY
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-2033
Practice Address - Country:US
Practice Address - Phone:615-859-9994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8834122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN15118461Medicaid
NC5902819Medicaid
NC90241OtherBCBS