Healthcare Provider Details

I. General information

NPI: 1013662246
Provider Name (Legal Business Name): DIAMOND PLUS ORTHODONTICS BY BUBON ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 GOLF MILL CTR STE 905
NILES IL
60714-1208
US

IV. Provider business mailing address

9130 W LOOMIS RD STE 600
FRANKLIN WI
53132-9091
US

V. Phone/Fax

Practice location:
  • Phone: 847-298-6030
  • Fax:
Mailing address:
  • Phone: 262-522-7447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: GRETCHEN WELLNER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 262-522-7447