Provider Demographics
NPI:1861612889
Name:SOUTHWORTH, ROBERT W (D M D)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:SOUTHWORTH
Suffix:
Gender:M
Credentials:D M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 NE 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5112
Mailing Address - Country:US
Mailing Address - Phone:503-249-0770
Mailing Address - Fax:503-280-1118
Practice Address - Street 1:1822 NE 33RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5112
Practice Address - Country:US
Practice Address - Phone:503-249-0770
Practice Address - Fax:503-280-1118
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR52201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice