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General NPI Number Information
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NPI Number | 1053848374
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Entity Type | Organization
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Legal Business Name | SUMMIT PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 05/17/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 24 NW CHIPMAN RD STE B
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City | LEES SUMMIT
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State | MO
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Zip | 64063-1929
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Country | US
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Telephone | 816-256-0073
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Fax |
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Provider Business Mailing Address
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Address Line | 24 NW CHIPMAN RD STE B
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City | LEES SUMMIT
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State | MO
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Zip | 64063-1929
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Country | US
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Telephone | 816-256-0073
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | MONCY MATHEW
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Credential | DDS
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Telephone | 816-256-0073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2006037222
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License Number State | MO
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