Provider Demographics
NPI:1881700250
Name:SOUTHERN, CYNTHIA MARTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:MARTIN
Last Name:SOUTHERN
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 1:62 E MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:VA
Mailing Address - Zip Code:24301
Mailing Address - Country:US
Mailing Address - Phone:540-280-5129
Mailing Address - Fax:540-980-5179
Practice Address - Street 1:62 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301
Practice Address - Country:US
Practice Address - Phone:540-280-5129
Practice Address - Fax:540-980-5179
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9178924Medicaid