MEDICARE: SUPER SMILES FOR KIDS, 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	1223P0221X	Pediatric Dentistry	07288	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750747150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPER SMILES FOR KIDS, LLC

Provider Business Mailing Address
First Line	:	1285 E SUNSET DR
Second Line	:
City	:	CASA GRANDE
State	:	AZ
Zip	:	85122-2942
Country	:	US
Telephone Number	:	520-442-0332
Fax Number	:

Provider Business Practice Location Address
First Line	:	1285 E SUNSET DR
Second Line	:
City	:	CASA GRANDE
State	:	AZ
Zip	:	85122-2942
Country	:	US
Telephone Number	:	520-442-0332
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR/ MEMBER
Name	:	DORA PESQUEDA
Credential	:
Telephone Number	:	520-442-0332

Provider Enumeration Date	:	01/14/2016
Last Update Date	:	04/03/2026

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Directions to “SUPER SMILES FOR KIDS, LLC ” Practice Location

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