Provider Demographics
NPI:1538410873
Name:JOHN WALSH DDS PA
Entity type:Organization
Organization Name:JOHN WALSH DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-522-1550
Mailing Address - Street 1:202 E WOODLAWN RD
Mailing Address - Street 2:STE 114
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-2213
Mailing Address - Country:US
Mailing Address - Phone:704-522-1550
Mailing Address - Fax:704-522-1558
Practice Address - Street 1:8401 MEDICAL PLAZA DR
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8797
Practice Address - Country:US
Practice Address - Phone:704-593-1090
Practice Address - Fax:704-593-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC82471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty