Healthcare Provider Details

I. General information

NPI: 1215864905
Provider Name (Legal Business Name): ST. JOSEPH FAMILY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3904 BECK RD STE 110
SAINT JOSEPH MO
64506-5037
US

IV. Provider business mailing address

3904 BECK RD STE 110
SAINT JOSEPH MO
64506-5037
US

V. Phone/Fax

Practice location:
  • Phone: 816-233-2672
  • Fax: 816-233-4725
Mailing address:
  • Phone: 816-233-2672
  • Fax: 816-233-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. KAITLYN WALTERS
Title or Position: OWNER
Credential: DMD
Phone: 816-233-2672