Samuel John Douglas, DDS

Primary specialty

DentistTaxonomy code 122300000X

License

2024021490 Issued in MO

Practice address

519 SW 3Rd St Ste G
Lees Summit, MO 64063-2278

Phone

(816) 524-3434

NPI assigned

May 21, 2024

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Jun 12, 2024 through Jun 12, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• J and E Dental LLC

  • General Practice Dentistry
  • Lees Summit, MO
  • NPI 1598686347
  NPD (past)
• Roger L Fender DDS

  • Dentist
  • Lees Summit, MO
  • NPI 1295719417
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1716249600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1718064000000",
    "number": "1124867924",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "519 SW 3RD ST STE G",
            "city": "LEES SUMMIT",
            "state": "MO",
            "postal_code": "640632278",
            "telephone_number": "816-524-3434"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "519 SW 3RD ST STE G",
            "city": "LEES SUMMIT",
            "state": "MO",
            "postal_code": "640632278",
            "telephone_number": "816-524-3434"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DOUGLAS",
        "first_name": "SAMUEL",
        "middle_name": "JOHN",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2024-05-21",
        "last_updated": "2024-06-11",
        "certification_date": "2024-06-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "MO",
            "license": "2024021490",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Meghan Kaye Donohue, PTA
• Nicholas Donohue
• Doris House, LPC, PC
• Ryan Dougherty, DPT
• Douglas B Vaughan PHD PC
• Sean Joseph Dowling
• Demi Downs
• Dr Amanda Fisher DPT LLC
• Dr James a Green PC
• Dr. Herbert E. Dempsey LLC

• Dentist in Lees Summit, MO
• Providers in Lees Summit, MO by specialty
• Dentist in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 11, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.