Provider Demographics
NPI:1447946090
Name:MCINTOSH, KEITH ERIC JR (DMD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ERIC
Last Name:MCINTOSH
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12450 CLEVELAND RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-8355
Mailing Address - Country:US
Mailing Address - Phone:919-772-9927
Mailing Address - Fax:919-772-0647
Practice Address - Street 1:12450 CLEVELAND RD STE 100
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-8355
Practice Address - Country:US
Practice Address - Phone:919-772-9927
Practice Address - Fax:919-772-0647
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC134831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program