Healthcare Provider Details

I. General information

NPI: 1487695169
Provider Name (Legal Business Name): DOUGLAS MACDOWELL WALTERS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 NICHOLS RD SUITE 236
KANSAS CITY MO
64112-2000
US

IV. Provider business mailing address

411 NICHOLS RD SUITE 236
KANSAS CITY MO
64112-2000
US

V. Phone/Fax

Practice location:
  • Phone: 816-753-0202
  • Fax: 816-753-0253
Mailing address:
  • Phone: 816-753-0202
  • Fax: 816-753-0253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2002011684
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: