Healthcare Provider Details

I. General information

NPI: 1114135548
Provider Name (Legal Business Name): CRYSTAL L MCINTOSH DDS,MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W ST NW WASHINGTON DC
WASHINGTON DC
20059-1022
US

IV. Provider business mailing address

5304 ILLINOIS AVE NW
WASHINGTON DC
20011-3906
US

V. Phone/Fax

Practice location:
  • Phone: 202-806-0322
  • Fax:
Mailing address:
  • Phone: 240-508-9472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901019380
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDEN1000851
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: