Provider Demographics
NPI:1780935452
Name:JOHN WALSH DDS PA
Entity type:Organization
Organization Name:JOHN WALSH DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-522-1550
Mailing Address - Street 1:5821 FAIRVIEW RD
Mailing Address - Street 2:STE 220
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-5601
Mailing Address - Country:US
Mailing Address - Phone:704-522-1550
Mailing Address - Fax:704-522-1558
Practice Address - Street 1:1711 MONTFORD DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3721
Practice Address - Country:US
Practice Address - Phone:704-527-2440
Practice Address - Fax:704-527-2406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC43051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty