Provider Demographics
NPI:1649472465
Name:WALDE, KEVIN C (DDS, MS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:WALDE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1507 HERITAGE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4614
Mailing Address - Country:US
Mailing Address - Phone:636-239-5151
Mailing Address - Fax:636-390-2728
Practice Address - Street 1:1507 HERITAGE HILLS DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4614
Practice Address - Country:US
Practice Address - Phone:636-239-5151
Practice Address - Fax:636-390-2728
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0139361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics