Provider Demographics
NPI:1134180714
Name:PETICOLAS, CYNTHIA MARION (DMD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:MARION
Last Name:PETICOLAS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 260
Mailing Address - Street 2:
Mailing Address - City:MILL CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97360
Mailing Address - Country:US
Mailing Address - Phone:503-897-2353
Mailing Address - Fax:503-897-2354
Practice Address - Street 1:548 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MILL CITY
Practice Address - State:OR
Practice Address - Zip Code:97360
Practice Address - Country:US
Practice Address - Phone:503-897-2353
Practice Address - Fax:503-897-2354
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR59861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR265439Medicaid