Healthcare Provider Details

I. General information

NPI: 1831001825
Provider Name (Legal Business Name): ORTHO 360 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3726 ROOSEVELT RD
KENOSHA WI
53142-1900
US

IV. Provider business mailing address

3726 ROOSEVELT RD
KENOSHA WI
53142-1900
US

V. Phone/Fax

Practice location:
  • Phone: 877-786-0360
  • Fax:
Mailing address:
  • Phone: 877-795-0360
  • 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: IVANA BUENO
Title or Position: DIRECTOR
Credential:
Phone: 773-798-9382