Healthcare Provider Details

I. General information

NPI: 1902046915
Provider Name (Legal Business Name): CYNTHIA ROSE NOLL DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2417 MCGUIRE BLVD
MC GUIRE AFB NJ
08641-5116
US

IV. Provider business mailing address

2417 MCGUIRE BLVD
APO AA
08640
US

V. Phone/Fax

Practice location:
  • Phone: 609-754-3786
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8790
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: