Provider Demographics
NPI:1235722794
Name:WALSH, SHANNON ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:WALSH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 JANET LN
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-5000
Mailing Address - Country:US
Mailing Address - Phone:978-532-1305
Mailing Address - Fax:
Practice Address - Street 1:11 EAST ST
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:MA
Practice Address - Zip Code:01949-1506
Practice Address - Country:US
Practice Address - Phone:978-817-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2022-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18591201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program