MEDICARE: CEDAR SMILES 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

General Provider Information

NPI Number	:	1437968716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR SMILES LLC

Provider Business Mailing Address
First Line	:	1751 W ROYAL HUNTE DR STE B
Second Line	:
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-1865
Country	:	US
Telephone Number	:	435-865-9111
Fax Number	:

Provider Business Practice Location Address
First Line	:	1751 W ROYAL HUNTE DR STE B
Second Line	:
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-1865
Country	:	US
Telephone Number	:	435-865-9111
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL DEAN KOFFORD
Credential	:	DMD
Telephone Number	:	719-331-2504

Provider Enumeration Date	:	01/02/2025
Last Update Date	:	01/02/2025

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Directions to “CEDAR SMILES LLC ” Practice Location

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