Healthcare Provider Details

I. General information

NPI: 1205794468
Provider Name (Legal Business Name): SMILE VISTA KIDS DENTISTRY & ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2026
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4499 W 38TH AVE UNIT 101
DENVER CO
80212-2199
US

IV. Provider business mailing address

4499 W 38TH AVE UNIT 101
DENVER CO
80212-2199
US

V. Phone/Fax

Practice location:
  • Phone: 303-827-0606
  • Fax: 303-827-0606
Mailing address:
  • Phone: 303-827-0606
  • Fax: 303-827-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CASSANDRA WIETH
Title or Position: DIRECTOR OF PAYOR RELATIONS
Credential:
Phone: 623-267-8121