Healthcare Provider Details

I. General information

NPI: 1881982221
Provider Name (Legal Business Name): PRAIRIE ORTHDONTICS S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5024 N GREENBAY RD SUITE 150
KENOSHA WI
53144-1714
US

IV. Provider business mailing address

5024 N GREENBAY RD SUITE 150
KENOSHA WI
53144-1714
US

V. Phone/Fax

Practice location:
  • Phone: 262-637-8800
  • Fax:
Mailing address:
  • Phone: 262-637-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6500-15
License Number StateWI

VIII. Authorized Official

Name: DR. MICHAEL G. WEINBERG
Title or Position: ORTHODONTIST
Credential: D.M.D.
Phone: 262-637-8800