Healthcare Provider Details

I. General information

NPI: 1043135643
Provider Name (Legal Business Name): MO SMILES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6359 AIRPORT RD
SEDALIA CO
80135-8840
US

IV. Provider business mailing address

6359 AIRPORT RD
SEDALIA CO
80135-8840
US

V. Phone/Fax

Practice location:
  • Phone: 720-627-7734
  • Fax:
Mailing address:
  • Phone: 720-627-7734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN TERRY CANDELAS
Title or Position: MANAGER
Credential:
Phone: 303-582-4157