Provider Demographics
NPI:1598332496
Name:SOUTHALL, PAYTON (DDS)
Entity type:Individual
Prefix:DR
First Name:PAYTON
Middle Name:
Last Name:SOUTHALL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:PAYTON
Other - Middle Name:
Other - Last Name:SOUTHALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:220 RAGLAND RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-9721
Mailing Address - Country:US
Mailing Address - Phone:304-252-0472
Mailing Address - Fax:
Practice Address - Street 1:220 RAGLAND RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-9721
Practice Address - Country:US
Practice Address - Phone:304-252-0472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0266021223G0001X
WV45111223P0221X, 122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program