Provider Demographics
NPI:1336636869
Name:FORD, CYNTHIA LYNN (RDA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LYNN
Last Name:FORD
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25590 PROSPECT AVE APT 8E
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3144
Mailing Address - Country:US
Mailing Address - Phone:909-915-4523
Mailing Address - Fax:
Practice Address - Street 1:25590 PROSPECT AVE APT 8E
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3144
Practice Address - Country:US
Practice Address - Phone:909-915-4523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA87790126800000X
CA126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126800000XDental ProvidersDental AssistantGroup - Single Specialty