MEDICARE: SMILE VISTA KIDS DENTISTRY & ORTHODONTICS 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
2	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1205794468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE VISTA KIDS DENTISTRY & ORTHODONTICS LLC

Provider Business Mailing Address
First Line	:	4499 W 38TH AVE UNIT 101
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80212-2199
Country	:	US
Telephone Number	:	303-827-0606
Fax Number	:	303-827-0606

Provider Business Practice Location Address
First Line	:	4499 W 38TH AVE UNIT 101
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80212-2199
Country	:	US
Telephone Number	:	303-827-0606
Fax Number	:	303-827-0606

Authorized Official
Title or Position	:	DIRECTOR OF PAYOR RELATIONS
Name	:	CASSANDRA WIETH
Credential	:
Telephone Number	:	623-267-8121

Provider Enumeration Date	:	01/14/2026
Last Update Date	:	01/14/2026

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