Provider Demographics
NPI:1457374787
Name:MCINTYRE, MONICA (DDS)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:MCINTYRE
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 1:12 ROUNTREE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4036
Mailing Address - Country:US
Mailing Address - Phone:678-479-7001
Mailing Address - Fax:678-479-7007
Practice Address - Street 1:12 ROUNTREE RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4036
Practice Address - Country:US
Practice Address - Phone:678-479-7001
Practice Address - Fax:678-479-7007
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0124671223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000925735GMedicaid
GA000925735AMedicaid