Healthcare Provider Details

I. General information

NPI: 1770597411
Provider Name (Legal Business Name): RODERICK M MACINTYRE III D.M.D.; M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 S RIDGEWOOD AVE SUITE C
DAYTONA BEACH FL
32114-5349
US

IV. Provider business mailing address

912 S RIDGEWOOD AVE SUITE C
DAYTONA BEACH FL
32114-5349
US

V. Phone/Fax

Practice location:
  • Phone: 386-252-0858
  • Fax: 386-253-7004
Mailing address:
  • Phone: 386-252-0858
  • Fax: 386-253-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN12743
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: