Provider Demographics
NPI:1154713246
Name:DR. CYNTHIA D. PARKS DDS, PLLC
Entity type:Organization
Organization Name:DR. CYNTHIA D. PARKS DDS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-777-4114
Mailing Address - Street 1:7000 COOMB'S FARM DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-7310
Mailing Address - Country:US
Mailing Address - Phone:304-777-4114
Mailing Address - Fax:304-777-4115
Practice Address - Street 1:7000 COOMB'S FARM DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-7310
Practice Address - Country:US
Practice Address - Phone:304-777-4114
Practice Address - Fax:304-777-4115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD136881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD012065100Medicaid
WV3810006975Medicaid