Healthcare Provider Details

I. General information

NPI: 1578592333
Provider Name (Legal Business Name): CYNTHIA JOY COOTAUCO D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7939 HONEYGO BLVD
BALTIMORE MD
21236-4931
US

IV. Provider business mailing address

3027 BLACKROCK RD
REISTERSTOWN MD
21136-3816
US

V. Phone/Fax

Practice location:
  • Phone: 410-931-0250
  • Fax: 410-931-4876
Mailing address:
  • Phone: 410-472-4724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number11615
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: