Provider Demographics
NPI:1205993417
Name:BURROUGHS, CYNTHIA GRAVES (DMD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:GRAVES
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TOMPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42167-1505
Mailing Address - Country:US
Mailing Address - Phone:270-487-5545
Mailing Address - Fax:270-487-5812
Practice Address - Street 1:101 W 4TH ST
Practice Address - Street 2:
Practice Address - City:TOMPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42167-1505
Practice Address - Country:US
Practice Address - Phone:270-487-5545
Practice Address - Fax:270-487-5812
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY66331223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist