Provider Demographics
NPI:1952887374
Name:WINNEBAGO BRACES, LLC.
Entity Type:Organization
Organization Name:WINNEBAGO BRACES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CO-FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-882-2569
Mailing Address - Street 1:4849 N MILWAUKEE AVE STE 403
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2169
Mailing Address - Country:US
Mailing Address - Phone:312-946-2080
Mailing Address - Fax:
Practice Address - Street 1:555 N COURT ST STE 110
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-6898
Practice Address - Country:US
Practice Address - Phone:815-733-2550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty