Provider Demographics
NPI:1851366512
Name:LIFE, COMMISSO, & WALSH DMD'S PC
Entity Type:Organization
Organization Name:LIFE, COMMISSO, & WALSH DMD'S PC
Other - Org Name:MEADOW PLACE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:413-525-6123
Mailing Address - Street 1:200 N. MAIN STREET
Mailing Address - Street 2:SUITE 1102
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028
Mailing Address - Country:US
Mailing Address - Phone:413-525-6123
Mailing Address - Fax:413-525-8999
Practice Address - Street 1:200 N. MAIN STREET
Practice Address - Street 2:SUITE 1102
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028
Practice Address - Country:US
Practice Address - Phone:413-525-6123
Practice Address - Fax:413-525-8999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA132611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty