Provider Demographics
NPI:1285828343
Name:SULLIVAN WALSH, MEGHAN MAUREEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MEGHAN
Middle Name:MAUREEN
Last Name:SULLIVAN WALSH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MEGHAN
Other - Middle Name:MAUREEN
Other - Last Name:SULLIVAN WALSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:128 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08560-1731
Mailing Address - Country:US
Mailing Address - Phone:267-475-7351
Mailing Address - Fax:
Practice Address - Street 1:3223 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5007
Practice Address - Country:US
Practice Address - Phone:215-707-2803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0407511223P0221X
NC84871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice