MEDICARE: DR. KAITLYN HEIDEL WALTERS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2013019323	MO

General Provider Information

NPI Number	:	1457791386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAITLYN HEIDEL WALTERS DMD

Provider Business Mailing Address
First Line	:	3904 BECK RD
Second Line	:	STE. 110
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-4952
Country	:	US
Telephone Number	:	816-279-2299
Fax Number	:	816-233-4725

Provider Business Practice Location Address
First Line	:	3904 BECK RD
Second Line	:	STE. 110
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-4952
Country	:	US
Telephone Number	:	816-279-2299
Fax Number	:	816-233-4725

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2013
Last Update Date	:	06/25/2013

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