Provider Demographics
NPI:1598011462
Name:WALSH, GREGORY BURGESS (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:BURGESS
Last Name:WALSH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6560 W FULLERTON AVE
Mailing Address - Street 2:UNIT C106 SUITE T
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3439
Mailing Address - Country:US
Mailing Address - Phone:415-572-6308
Mailing Address - Fax:
Practice Address - Street 1:6560 W FULLERTON AVE
Practice Address - Street 2:UNIT C106 SUITE T
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707-3439
Practice Address - Country:US
Practice Address - Phone:415-572-6308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029172122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist