Provider Demographics
NPI:1952523193
Name:SOUTHALL, TODD DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:DAVID
Last Name:SOUTHALL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD77871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice