Healthcare Provider Details

I. General information

NPI: 1285828343
Provider Name (Legal Business Name): MEGHAN MAUREEN SULLIVAN WALSH D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MEGHAN MAUREEN SULLIVAN WALSH D.M.D.

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 N BROAD ST
PHILADELPHIA PA
19140-5007
US

IV. Provider business mailing address

128 RIVER DR
TITUSVILLE NJ
08560-1731
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-2803
  • Fax:
Mailing address:
  • Phone: 267-475-7351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS040751
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8487
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: