Provider Demographics
NPI:1811906829
Name:WALSH, STEPHEN ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ROBERT
Last Name:WALSH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 WOODMOOR DR
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-9091
Mailing Address - Country:US
Mailing Address - Phone:719-481-8321
Mailing Address - Fax:719-481-8405
Practice Address - Street 1:1840 WOODMOOR DR
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-9091
Practice Address - Country:US
Practice Address - Phone:719-481-8321
Practice Address - Fax:719-481-8405
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHDL 7210122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02072106Medicaid
AL550 07357OtherBCBS ALABAMA
7210OtherDELTA
785552OtherUNITED CONCORDIA