Provider Demographics
NPI:1619976404
Name:MCINTYRE, PETER AUGUSTINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:AUGUSTINE
Last Name:MCINTYRE
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 1:595 CHAPEL HILLS DRIVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920
Mailing Address - Country:US
Mailing Address - Phone:719-475-2511
Mailing Address - Fax:719-475-8425
Practice Address - Street 1:595 CHAPEL HILLS DR
Practice Address - Street 2:SUITE 105
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1022
Practice Address - Country:US
Practice Address - Phone:719-475-2511
Practice Address - Fax:719-475-8425
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1062391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02106235Medicaid