Provider Demographics
NPI:1316063530
Name:WALSH, MICHAEL ANTHONY (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
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 1:2600 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-4813
Mailing Address - Country:US
Mailing Address - Phone:262-658-1410
Mailing Address - Fax:262-658-1448
Practice Address - Street 1:2600 22ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4813
Practice Address - Country:US
Practice Address - Phone:262-658-1410
Practice Address - Fax:262-658-1448
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001276-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice