Healthcare Provider Details

I. General information

NPI: 1992357453
Provider Name (Legal Business Name): BRACE YOURSELF ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16329 STATE ROAD 23
SOUTH BEND IN
46635-1457
US

IV. Provider business mailing address

16329 STATE ROAD 23
SOUTH BEND IN
46635-1457
US

V. Phone/Fax

Practice location:
  • Phone: 574-243-8843
  • Fax:
Mailing address:
  • Phone: 574-243-8843
  • 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: MIKE COLE
Title or Position: VP INSURANCE PLAN MANAGEMENT
Credential:
Phone: 941-955-3150