Healthcare Provider Details

I. General information

NPI: 1649472465
Provider Name (Legal Business Name): KEVIN C WALDE D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 HERITAGE HILLS DR
WASHINGTON MO
63090-4614
US

IV. Provider business mailing address

1507 HERITAGE HILLS DR
WASHINGTON MO
63090-4614
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-5151
  • Fax: 636-390-2728
Mailing address:
  • Phone: 636-239-5151
  • Fax: 636-390-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number013936
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: