Provider Demographics
NPI:1386658284
Name:EAST COAST ENDODONTICS
Entity type:Organization
Organization Name:EAST COAST ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:MACINTYRE
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD;MS
Authorized Official - Phone:386-252-0858
Mailing Address - Street 1:912 S RIDGEWOOD AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5349
Mailing Address - Country:US
Mailing Address - Phone:386-252-0858
Mailing Address - Fax:386-253-7004
Practice Address - Street 1:912 S RIDGEWOOD AVE
Practice Address - Street 2:SUITE C
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5349
Practice Address - Country:US
Practice Address - Phone:386-252-0858
Practice Address - Fax:386-253-7004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12743261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental