Provider Demographics
NPI:1891083960
Name:WALKER, MARY HAGAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:HAGAN
Last Name:WALKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:HAGAN
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2 GREGORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06855-2021
Mailing Address - Country:US
Mailing Address - Phone:316-258-4484
Mailing Address - Fax:
Practice Address - Street 1:2260 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-2413
Practice Address - Country:US
Practice Address - Phone:316-258-4484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010571122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist