Provider Demographics
NPI:1356528558
Name:GLEN C MCINTOSH D.D.S., P.C.
Entity type:Organization
Organization Name:GLEN C MCINTOSH D.D.S., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-476-8576
Mailing Address - Street 1:3400 MCCLURE BRIDGE ROAD
Mailing Address - Street 2:BUILDING G SUITE B
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096
Mailing Address - Country:US
Mailing Address - Phone:770-476-8576
Mailing Address - Fax:770-623-9714
Practice Address - Street 1:3400 MCCLURE BRIDGE ROAD
Practice Address - Street 2:BUILDING G SUITE B
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:770-476-8576
Practice Address - Fax:770-623-9714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty