Organization
WINNEBAGO BRACES, LLC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SCOTT GOLDMAN DDS (CEO/CO-FOUNDER)
(312) 882-2569
Entity
Organization
Contact information
Practice address
555 N COURT ST STE 110, ROCKFORD, IL 61103-6898
(815) 733-2550
Mailing address
4849 N MILWAUKEE AVE STE 403, CHICAGO, IL 60630-2169
(312) 946-2080
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
—
—
1223G0001X
General Practice Dentistry
—
—
1223P0221X
Pediatric Dentistry
—
—
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
—
—
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
—
—
Other
Enumeration date
07/18/2018
Last updated
07/18/2018
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