Provider Demographics
NPI:1518632090
Name:SUMMIT FAMILY DENTAL ARTS LLC
Entity Type:Organization
Organization Name:SUMMIT FAMILY DENTAL ARTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-721-8334
Mailing Address - Street 1:4045 NE LAKEWOOD WAY STE 150
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-1997
Mailing Address - Country:US
Mailing Address - Phone:816-350-9119
Mailing Address - Fax:
Practice Address - Street 1:1701 SW US HIGHWAY 40 STE 202
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-4647
Practice Address - Country:US
Practice Address - Phone:816-229-2442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1659829588OtherNPI
MO1083900021OtherNPI