1154713246 NPI number — DR. CYNTHIA D. PARKS DDS, PLLC

Table of content: (NPI 1154713246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154713246 NPI number — DR. CYNTHIA D. PARKS DDS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. CYNTHIA D. PARKS DDS, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154713246
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7000 COOMB'S FARM DRIVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26508-7310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-777-4114
Provider Business Mailing Address Fax Number:
304-777-4115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7000 COOMB'S FARM DRIVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26508-7310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-777-4114
Provider Business Practice Location Address Fax Number:
304-777-4115
Provider Enumeration Date:
02/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PARKS
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
DENISE
Authorized Official Title or Position:
PEDIATRIC DENTIST
Authorized Official Telephone Number:
304-777-4114

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  13688 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 012065100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810006975 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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