Provider Demographics
NPI:1104293091
Name:SOUTHWORTH, BARBARA (RDH)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:
Other - Last Name:FEHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1904 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724-1291
Mailing Address - Country:US
Mailing Address - Phone:715-296-1649
Mailing Address - Fax:
Practice Address - Street 1:1904 5TH AVE
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724-1291
Practice Address - Country:US
Practice Address - Phone:715-296-1649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5432-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist