Provider Demographics
NPI:1013662246
Name:DIAMOND PLUS ORTHODONTICS BY BUBON ORTHODONTICS
Entity Type:Organization
Organization Name:DIAMOND PLUS ORTHODONTICS BY BUBON ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-522-7447
Mailing Address - Street 1:9130 W LOOMIS RD STE 600
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9091
Mailing Address - Country:US
Mailing Address - Phone:262-522-7447
Mailing Address - Fax:
Practice Address - Street 1:241 GOLF MILL CTR STE 905
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-1208
Practice Address - Country:US
Practice Address - Phone:847-298-6030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BUBON & ASSOCIATES, ORTHODONTICS, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty