1518033174 NPI number — DR. KEVIN MARTIN WALSH DDS MS

Table of content: DR. KEVIN MARTIN WALSH DDS MS (NPI 1518033174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518033174 NPI number — DR. KEVIN MARTIN WALSH DDS MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALSH
Provider First Name:
KEVIN
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS MS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518033174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6651 CHIPPEWA SUITE 221
Provider Second Line Business Mailing Address:
LANSDOWNE MEDICAL BUILDING
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63109-2531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-351-2588
Provider Business Mailing Address Fax Number:
314-351-3334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6651 CHIPPEWA
Provider Second Line Business Practice Location Address:
SUITE 221
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63109-2531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-351-2588
Provider Business Practice Location Address Fax Number:
314-351-3334
Provider Enumeration Date:
11/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  00580 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2012963 . This is a "DELTA DENTAL INSURANCE" identifier . This identifiers is of the category "OTHER".




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