Healthcare Provider Details

I. General information

NPI: 1114868957
Provider Name (Legal Business Name): SUMMIT ORAL SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2026
Last Update Date: 04/04/2026
Certification Date: 04/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19921 E JACKSON DR
INDEPENDENCE MO
64057-1596
US

IV. Provider business mailing address

19921 E JACKSON DR
INDEPENDENCE MO
64057-1596
US

V. Phone/Fax

Practice location:
  • Phone: 313-600-2188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL LEE
Title or Position: ADMINISTRATOR
Credential: DDS
Phone: 313-600-2188