Provider Demographics
NPI:1184811622
Name:WALSH, JOHN J (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:WALSH
Suffix:
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 1:935 RIVERDALE ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-4656
Mailing Address - Country:US
Mailing Address - Phone:413-841-0075
Mailing Address - Fax:
Practice Address - Street 1:935 RIVERDALE ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-4656
Practice Address - Country:US
Practice Address - Phone:413-841-0075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16396122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist