Provider Demographics
NPI:1235442997
Name:BOUCHARD-LAVENKA, CYNTHIA RENEE (DMD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:RENEE
Last Name:BOUCHARD-LAVENKA
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12150 W SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2227
Mailing Address - Country:US
Mailing Address - Phone:954-669-1469
Mailing Address - Fax:954-669-1468
Practice Address - Street 1:12150 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33323-2227
Practice Address - Country:US
Practice Address - Phone:954-669-1469
Practice Address - Fax:954-669-1468
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL889390200000X
FLDN190511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program