Provider Demographics
NPI:1104032713
Name:WELSH, MARK W (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:WELSH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 TROY RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9447
Mailing Address - Country:US
Mailing Address - Phone:607-277-1307
Mailing Address - Fax:
Practice Address - Street 1:324 DRYDEN RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4726
Practice Address - Country:US
Practice Address - Phone:607-272-1921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist