Basic Information
| Provider Information | |||||||||
| NPI: | 1659461952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOUDELA | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S., M.S.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6950 NE CAMPUS WAY | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971245611 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11011 MERIDIAN AVE N | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981338967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063650378 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2006 | ||||||||
| LastUpdateDate: | 06/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | DE00006021 | WA | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
ID Information
| ID | Type | State | Issuer | Description | 0113407 | 05 | MT | MEDICAID | 807251600 | 05 | ID | MEDICAID | DD474WA | 05 | AK | MEDICAID | 5048822 | 05 | WA | MEDICAID |