Basic Information
Provider Information
NPI: 1194017376
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WALSH
FirstName: MARTIN
MiddleName: WILLIAM
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 625 NORTON ST
Address2:  
City: TRAVIS AFB
State: CA
PostalCode: 945351357
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 101 BODIN CIR
Address2:  
City: TRAVIS AFB
State: CA
PostalCode: 945351809
CountryCode: US
TelephoneNumber: 7074237085
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/06/2011
LastUpdateDate: 04/15/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X6693WIY Dental ProvidersDentist 

No ID Information.


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