MEDICARE: DR. SUMMER KETRON ROARK D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	27872	TX

General Provider Information

NPI Number	:	1083913198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUMMER KETRON ROARK D.D.S.

Provider Business Mailing Address
First Line	:	4905 78TH ST
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79424-3103
Country	:	US
Telephone Number	:	806-928-2080
Fax Number	:

Provider Business Practice Location Address
First Line	:	5301 50TH ST STE 100
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79414-5834
Country	:	US
Telephone Number	:	806-793-3556
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2011
Last Update Date	:	02/20/2025

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