Provider Demographics
NPI:1881982221
Name:PRAIRIE ORTHDONTICS S.C.
Entity type:Organization
Organization Name:PRAIRIE ORTHDONTICS S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:262-637-8800
Mailing Address - Street 1:5024 N GREENBAY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1714
Mailing Address - Country:US
Mailing Address - Phone:262-637-8800
Mailing Address - Fax:
Practice Address - Street 1:5024 N GREENBAY RD
Practice Address - Street 2:SUITE 150
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1714
Practice Address - Country:US
Practice Address - Phone:262-637-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIE ORTHODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-19
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6500-151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty