MEDICARE: SUMMIT DENTAL HEALTH - CENTER LLC

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

General Provider Information

NPI Number	:	1275941734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMIT DENTAL HEALTH - CENTER LLC

Provider Business Mailing Address
First Line	:	134 EVERGREEN RD STE 200
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40243-1486
Country	:	US
Telephone Number	:	502-254-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	5321 CENTER ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68106-2338
Country	:	US
Telephone Number	:	402-551-2238
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	STEVE JAMES
Credential	:
Telephone Number	:	502-254-8504

Provider Enumeration Date	:	07/29/2014
Last Update Date	:	07/29/2014

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