Provider Demographics
NPI:1376198366
Name:PARK, CYNTHIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:
Last Name:PARK
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 1:5629 SHEALS LN
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1976
Mailing Address - Country:US
Mailing Address - Phone:703-474-4761
Mailing Address - Fax:
Practice Address - Street 1:8328 TRAFORD LN STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1667
Practice Address - Country:US
Practice Address - Phone:703-705-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014165541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice