Provider Demographics
NPI:1356454268
Name:MICIOTTO, CYNTHIA M (DDS)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:MICIOTTO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2158 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3106
Mailing Address - Country:US
Mailing Address - Phone:318-747-1690
Mailing Address - Fax:318-747-9711
Practice Address - Street 1:2158 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3106
Practice Address - Country:US
Practice Address - Phone:318-747-1690
Practice Address - Fax:318-747-9711
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA37841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice