Healthcare Provider Details

I. General information

NPI: 1841780715
Provider Name (Legal Business Name): CYNTHIA ODUKOMAIYA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3442 LITHIA PINECREST RD
VALRICO FL
33596-6301
US

IV. Provider business mailing address

10576 CORY LAKE DR
TAMPA FL
33647-2710
US

V. Phone/Fax

Practice location:
  • Phone: 813-605-1508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN23930
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: