Provider Demographics
NPI:1992363907
Name:WALSH, EDWARD JOHN (DDS)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOHN
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 1:14314 POTRANCO RD STE 109
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-2348
Mailing Address - Country:US
Mailing Address - Phone:830-219-1378
Mailing Address - Fax:
Practice Address - Street 1:14314 POTRANCO RD STE 109
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-2348
Practice Address - Country:US
Practice Address - Phone:830-219-1378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.026166122300000X, 1223P0221X
TX409121223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist