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General NPI Number Information
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NPI Number | 1952887374
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Entity Type | Organization
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Legal Business Name | WINNEBAGO BRACES, LLC.
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Dates
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Enumeration Date | 07/18/2018
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Last Update Date | 07/18/2018
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Provider Practice Location Address
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Address Line | 555 N COURT ST STE 110
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City | ROCKFORD
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State | IL
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Zip | 61103-6898
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Country | US
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Telephone | 815-733-2550
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Fax |
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Provider Business Mailing Address
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Address Line | 4849 N MILWAUKEE AVE STE 403
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City | CHICAGO
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State | IL
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Zip | 60630-2169
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Country | US
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Telephone | 312-946-2080
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Fax |
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Authorized Official
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Title or Position | CEO/CO-FOUNDER
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Name | DR. SCOTT GOLDMAN
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Credential | DDS
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Telephone | 312-882-2569
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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