Basic Information
| Provider Information | |||||||||
| NPI: | 1750331849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POPA | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 3527423264 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327783808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 3527423264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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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 | 122300000X | DN13779 | FL | Y | Dental Providers | Dentist | 1223G0001X | 30-01-8541 | OH | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 001848700 | 05 | FL | MEDICAID | 0788045 | 05 | OH | MEDICAID |