Healthcare Provider Details

I. General information

NPI: 1487282760
Provider Name (Legal Business Name): MARIE KATHLEEN WALSH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N 7TH ST
WEST MEMPHIS AR
72301-2001
US

IV. Provider business mailing address

900 N 7TH ST
WEST MEMPHIS AR
72301-2001
US

V. Phone/Fax

Practice location:
  • Phone: 870-735-3842
  • Fax: 870-394-4817
Mailing address:
  • Phone: 707-353-8428
  • Fax: 870-394-4817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11370
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4183-21
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4697
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: