Provider Demographics
NPI:1659330157
Name:INTISO, RICHARD MICHAEL (DMD PA)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:INTISO
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:INTISO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD PA
Mailing Address - Street 1:4 COMMONS AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062
Mailing Address - Country:US
Mailing Address - Phone:207-893-2001
Mailing Address - Fax:207-893-2006
Practice Address - Street 1:4 COMMONS AVE
Practice Address - Street 2:STE 2
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062
Practice Address - Country:US
Practice Address - Phone:207-893-2001
Practice Address - Fax:207-893-2006
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN3564122300000X
MADEN14936122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist