Provider Demographics
NPI:1457791386
Name:WALTERS, KAITLYN HEIDEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:KAITLYN
Middle Name:HEIDEL
Last Name:WALTERS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 BECK RD
Mailing Address - Street 2:STE. 110
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-4952
Mailing Address - Country:US
Mailing Address - Phone:816-279-2299
Mailing Address - Fax:816-233-4725
Practice Address - Street 1:3904 BECK RD
Practice Address - Street 2:STE. 110
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-4952
Practice Address - Country:US
Practice Address - Phone:816-279-2299
Practice Address - Fax:816-233-4725
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130193231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice