=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568593192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN JAMES WALSH, DMD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 04/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4664 MAHONING AVE NW
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44483-1419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-847-8122
-----------------------------------------------------
Fax | 330-847-8122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4664 MAHONING AVE NW
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44483-1419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-847-8122
-----------------------------------------------------
Fax | 330-847-8122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN JAMES WALSH JR.
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 330-847-8122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 30-021154
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------