Healthcare Provider Details

I. General information

NPI: 1396613568
Provider Name (Legal Business Name): SMILE STATION KIDS DENTISTRY AND ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 DUTCHMANS CREEK DR STE A-B
BRUNSWICK MD
21716-9770
US

IV. Provider business mailing address

1201 DUTCHMANS CREEK DR STE A-B
BRUNSWICK MD
21716-9770
US

V. Phone/Fax

Practice location:
  • Phone: 301-900-4981
  • Fax:
Mailing address:
  • Phone: 301-900-4981
  • Fax:

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