Healthcare Provider Details

I. General information

NPI: 1720480957
Provider Name (Legal Business Name): LYNNETTE CIPOLLA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 NEALY AVENUE 633D MEDICAL GROUP
JOINT BASE LANGLEY-EUSTIS VA
23665-2040
US

IV. Provider business mailing address

77 NEALY AVENUE 633D MEDICAL GROUP
JOINT BASE LANGLEY-EUSTIS VA
23665-2040
US

V. Phone/Fax

Practice location:
  • Phone: 757-225-7630
  • Fax:
Mailing address:
  • Phone: 757-225-7630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number8281
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: