Provider Demographics
NPI:1467472100
Name:MCINNIS, DANIEL ANGUS (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ANGUS
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 W SHAW ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAULS
Mailing Address - State:NC
Mailing Address - Zip Code:28384-1428
Mailing Address - Country:US
Mailing Address - Phone:910-865-4152
Mailing Address - Fax:910-865-1009
Practice Address - Street 1:543 W SHAW ST
Practice Address - Street 2:
Practice Address - City:SAINT PAULS
Practice Address - State:NC
Practice Address - Zip Code:28384-1428
Practice Address - Country:US
Practice Address - Phone:910-865-4152
Practice Address - Fax:910-865-1009
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
558959OtherUNITED CONCORDIA INS.
NC8995770Medicaid
95770OtherBLUE CROSS/BLUE SHIELD
U38553Medicare UPIN