Provider Demographics
NPI:1982998381
Name:SOUTHWORTH, ROBERT HURD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:HURD
Last Name:SOUTHWORTH
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 1:609 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-5550
Mailing Address - Country:US
Mailing Address - Phone:715-842-1935
Mailing Address - Fax:715-842-0334
Practice Address - Street 1:609 JACKSON ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-5550
Practice Address - Country:US
Practice Address - Phone:715-842-1935
Practice Address - Fax:715-842-0334
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50016281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice