Healthcare Provider Details

I. General information

NPI: 1932204765
Provider Name (Legal Business Name): WALDE ORTHODONTIC ASSOCIATES DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
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: DR. KEVIN C WALDE
Title or Position: OWNER, ORTHODONTIST
Credential: DDS, MS
Phone: 636-239-5151