Healthcare Provider Details

I. General information

NPI: 1689538464
Provider Name (Legal Business Name): AUGUSTINE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 NE DOUGLAS ST
LEES SUMMIT MO
64063-2037
US

IV. Provider business mailing address

103 NE DOUGLAS ST
LEES SUMMIT MO
64063-2037
US

V. Phone/Fax

Practice location:
  • Phone: 816-524-1337
  • Fax:
Mailing address:
  • Phone: 816-524-1337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ASHLI GILL
Title or Position: PRACTICE ADMINISTRATOR
Credential: MBA
Phone: 785-766-2363