Healthcare Provider Details

I. General information

NPI: 1104552918
Provider Name (Legal Business Name): CYNTHIA LYNNE SENIOR RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

407 WARWICK RD
CLINTON MS
39056-6212
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-8808
  • Fax:
Mailing address:
  • Phone: 228-861-1545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3531-05DH
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: