Provider Demographics
NPI:1841404704
Name:MICHAEL A WALSH DDS SC
Entity Type:Organization
Organization Name:MICHAEL A WALSH DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-658-1410
Mailing Address - Street 1:2600 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140
Mailing Address - Country:US
Mailing Address - Phone:262-658-1410
Mailing Address - Fax:262-658-1448
Practice Address - Street 1:2600 22ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140
Practice Address - Country:US
Practice Address - Phone:262-658-1410
Practice Address - Fax:262-658-1410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50012760151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty