Northwest Pediatric Dental LLC

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

Legal business name

NORTHWEST PEDIATRIC DENTAL LLC

Doing business as

Southwest Pediatric Dental

Practice address

8217 Wicker Ave
St. John, IN 46373

Phone

(219) 440-1710

NPI assigned

Jul 30, 2024

Last updated

Sep 18, 2026By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Cassandra Wieth

Title

Director of Payor Relations

Phone

(623) 267-8121

Specialties & licenses 2

Addresses

Other names 1

• Southwest Pediatric Dental Doing business as

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• James Robert Mitsos, DMD

  • Pediatric Dentistry
  • Orland Park, IL
  • NPI 1841712536

  General Practice

  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1722297600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1789689600000",
    "number": "1982433819",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8217 WICKER AVE",
            "city": "SAINT JOHN",
            "state": "IN",
            "postal_code": "463738878",
            "telephone_number": "219-440-1710"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8217 WICKER AVE",
            "city": "ST. JOHN",
            "state": "IN",
            "postal_code": "46373",
            "telephone_number": "219-440-1710"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHWEST PEDIATRIC DENTAL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-07-30",
        "last_updated": "2026-09-18",
        "certification_date": "2026-09-18",
        "status": "A",
        "authorized_official_last_name": "WIETH",
        "authorized_official_first_name": "CASSANDRA",
        "authorized_official_title_or_position": "DIRECTOR OF PAYOR RELATIONS",
        "authorized_official_telephone_number": "623-267-8121"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223P0221X",
            "taxonomy_group": "",
            "desc": "Dentist, Pediatric Dentistry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southwest Pediatric Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jose Enrique Negrete, LSW
• Jane Neidy
• Tamara A Nicksic, PT
• Mia Nisle
• Northshore Health Centers, Inc. (NorthShore St. John Community Health Center)
• Courtney Olavarria, RN
• Nicole Lynn Olen, RDN, CHC
• Michael Olenik, PHARMD
• Erica Ortega
• Bina K Parekh, DO

• Pediatric Dentistry in Saint John, IN
• Providers in Saint John, IN by specialty
• Pediatric Dentistry in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 18, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.