Healthcare Provider Details

I. General information

NPI: 1265385470
Provider Name (Legal Business Name): PERIODONTAL CARE LEE'S SUMMIT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3470 NE RALPH POWELL RD STE C
LEES SUMMIT MO
64064-2330
US

IV. Provider business mailing address

3470 NE RALPH POWELL RD STE C
LEES SUMMIT MO
64064-2330
US

V. Phone/Fax

Practice location:
  • Phone: 816-524-9800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY JOHNSON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 913-379-9498