=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790998151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIANE MCINTYRE DDS PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 05/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3941 WALLINGFORD AVE N
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98103-8247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-633-4007
-----------------------------------------------------
Fax | 206-633-2504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3941 WALLINGFORD AVE N
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98103-8247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-633-4007
-----------------------------------------------------
Fax | 206-633-2504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DIANE R. MCINTYRE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 206-633-4007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5288
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------