Provider Demographics
NPI:1427581065
Name:WALSH, MARK J (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:WALSH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4S615 KARNS RD
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-1508
Mailing Address - Country:US
Mailing Address - Phone:830-358-6353
Mailing Address - Fax:
Practice Address - Street 1:7325 FLAT ROCK LN
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-7389
Practice Address - Country:US
Practice Address - Phone:830-358-3538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX370391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry