=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811443849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCINTYRE ENDODONTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2016
-----------------------------------------------------
Last Update Date | 08/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 WOOD ST # 1
-----------------------------------------------------
City | HOPKINTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01748-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-686-7668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 MINE BROOK CT
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02038-2891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-440-5626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENDODONTIST
-----------------------------------------------------
Name | DR. JUDY D MCINTYRE
-----------------------------------------------------
Credential | DMD, MS
-----------------------------------------------------
Telephone | 323-337-3906
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | DN21942
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------