Provider Demographics
NPI:1336834092
Name:WALSH, KELIN (DDS)
Entity Type:Individual
Prefix:
First Name:KELIN
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 PELTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-3009
Mailing Address - Country:US
Mailing Address - Phone:347-466-1360
Mailing Address - Fax:
Practice Address - Street 1:10 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2524
Practice Address - Country:US
Practice Address - Phone:973-744-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02881500122300000X
FLDN26374122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist