Healthcare Provider Details

I. General information

NPI: 1336527993
Provider Name (Legal Business Name): BUBON & ASSOCIATES, ORTHODONTICS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1253 CORPORATE CENTER DR
OCONOMOWOC WI
53066-4891
US

IV. Provider business mailing address

N4W21680 BLUEMOUND RD
WAUKESHA WI
53186-2943
US

V. Phone/Fax

Practice location:
  • Phone: 262-522-7447
  • Fax: 262-522-7448
Mailing address:
  • Phone: 262-522-7447
  • Fax: 262-522-7448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4015-15
License Number StateWI

VIII. Authorized Official

Name: DR. MICHAEL BUBON
Title or Position: OWNER
Credential:
Phone: 262-522-7447