Provider Demographics
NPI:1184691495
Name:WALSH, JENNIFER GAVRILLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:GAVRILLEN
Last Name:WALSH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:JAMESON
Other - Last Name:GAVRILLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:200 N MAIN ST
Mailing Address - Street 2:SUITE 1104
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-2392
Mailing Address - Country:US
Mailing Address - Phone:413-525-6123
Mailing Address - Fax:413-525-8999
Practice Address - Street 1:200 N MAIN ST
Practice Address - Street 2:SUITE 1104
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-2392
Practice Address - Country:US
Practice Address - Phone:413-525-6123
Practice Address - Fax:413-525-8999
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice