Provider Demographics
NPI:1679105357
Name:PACKARD, CYNTHIA LYNN (RDH)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LYNN
Last Name:PACKARD
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:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:WALSH
Mailing Address - State:CO
Mailing Address - Zip Code:81090-0193
Mailing Address - Country:US
Mailing Address - Phone:719-529-9811
Mailing Address - Fax:
Practice Address - Street 1:900 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:CO
Practice Address - Zip Code:81073-1636
Practice Address - Country:US
Practice Address - Phone:719-529-9811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO202013124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO202013DHMedicaid