Provider Demographics
NPI:1952608846
Name:DR VICTOR L WALSH DMD PA
Entity Type:Organization
Organization Name:DR VICTOR L WALSH DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-684-7921
Mailing Address - Street 1:1313 ASTON AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2825
Mailing Address - Country:US
Mailing Address - Phone:601-684-7921
Mailing Address - Fax:601-684-7950
Practice Address - Street 1:1313 ASTON AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2825
Practice Address - Country:US
Practice Address - Phone:601-684-7921
Practice Address - Fax:601-684-7950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-11
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1619-741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00063300Medicaid