MEDICARE: SMILE DESIGN EAGLE CREEK 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1265388987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE DESIGN EAGLE CREEK LLC

Provider Business Mailing Address
First Line	:	12692 TAMIAMI TRL E
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34113-8431
Country	:	US
Telephone Number	:	239-417-6453
Fax Number	:	239-203-2355

Provider Business Practice Location Address
First Line	:	12692 TAMIAMI TRL E
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34113-8431
Country	:	US
Telephone Number	:	239-417-6453
Fax Number	:	239-203-2355

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	JULI RENEE MIETZNER
Credential	:
Telephone Number	:	217-540-5651

Provider Enumeration Date	:	03/05/2026
Last Update Date	:	03/05/2026

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