Provider Demographics
NPI:1558625913
Name:MCINTOSH, MOLLY CONSTANCE (DDS)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:CONSTANCE
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8602 CINNAMON CREEK DR
Mailing Address - Street 2:APT 715
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-5812
Mailing Address - Country:US
Mailing Address - Phone:206-713-9779
Mailing Address - Fax:
Practice Address - Street 1:8410 DATAPOINT DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3220
Practice Address - Country:US
Practice Address - Phone:210-617-5208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-30
Last Update Date:2012-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60297651122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist