MEDICARE: MOUNTAIN SMILES - HECK FAMILY DENTISTRY PLLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1366304966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN SMILES - HECK FAMILY DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	5120 CONGRESSIONAL CIR STE 100
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66049-5236
Country	:	US
Telephone Number	:	785-856-8550
Fax Number	:

Provider Business Practice Location Address
First Line	:	5120 CONGRESSIONAL CIR STE 100
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66049-5236
Country	:	US
Telephone Number	:	785-856-8550
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SR. MANAGER
Name	:	ANGEL GIMENEZ
Credential	:
Telephone Number	:	719-300-5933

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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