Provider Demographics
NPI:1265505127
Name:FULLER, L.CYNTHIA COE (RDH)
Entity Type:Individual
Prefix:
First Name:L.CYNTHIA
Middle Name:COE
Last Name:FULLER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4339 S 301ST DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-2971
Mailing Address - Country:US
Mailing Address - Phone:253-946-3207
Mailing Address - Fax:
Practice Address - Street 1:1404 CENTRAL AVE S
Practice Address - Street 2:SUITE101
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-7433
Practice Address - Country:US
Practice Address - Phone:206-296-4586
Practice Address - Fax:206-205-8012
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00001380124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5900873Medicaid