Provider Demographics
NPI:1568593192
Name:JOHN JAMES WALSH, DMD, LLC
Entity Type:Organization
Organization Name:JOHN JAMES WALSH, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:330-847-8122
Mailing Address - Street 1:4664 MAHONING AVE NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-1419
Mailing Address - Country:US
Mailing Address - Phone:330-847-8122
Mailing Address - Fax:330-847-8122
Practice Address - Street 1:4664 MAHONING AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-1419
Practice Address - Country:US
Practice Address - Phone:330-847-8122
Practice Address - Fax:330-847-8122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0211541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty