Healthcare Provider Details

I. General information

NPI: 1952887374
Provider Name (Legal Business Name): WINNEBAGO BRACES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N COURT ST STE 110
ROCKFORD IL
61103-6898
US

IV. Provider business mailing address

4849 N MILWAUKEE AVE STE 403
CHICAGO IL
60630-2169
US

V. Phone/Fax

Practice location:
  • Phone: 815-733-2550
  • Fax:
Mailing address:
  • Phone: 312-946-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTT GOLDMAN
Title or Position: CEO/CO-FOUNDER
Credential: DDS
Phone: 312-882-2569