Healthcare Provider Details

I. General information

NPI: 1518033174
Provider Name (Legal Business Name): KEVIN MARTIN WALSH DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6651 CHIPPEWA SUITE 221
ST LOUIS MO
63109-2531
US

IV. Provider business mailing address

6651 CHIPPEWA SUITE 221 LANSDOWNE MEDICAL BUILDING
ST LOUIS MO
63109-2531
US

V. Phone/Fax

Practice location:
  • Phone: 314-351-2588
  • Fax: 314-351-3334
Mailing address:
  • Phone: 314-351-2588
  • Fax: 314-351-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number00580
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: