Provider Demographics
NPI:1992874028
Name:MCINTOSH, PHILLIP GORDON JR (DMD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:GORDON
Last Name:MCINTOSH
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 BRECKENRIDGE LANE
Mailing Address - Street 2:1-E
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220
Mailing Address - Country:US
Mailing Address - Phone:502-459-7352
Mailing Address - Fax:502-459-7922
Practice Address - Street 1:3101 BRECKENRIDGE LANE
Practice Address - Street 2:1-E
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220
Practice Address - Country:US
Practice Address - Phone:502-459-7352
Practice Address - Fax:502-459-7922
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5469122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist