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General NPI Number Information
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NPI Number | 1255163341
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Entity Type | Organization
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Legal Business Name | TIED MAIN LINE TONGUE TIE PROFESSIONALS.
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Dates
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Enumeration Date | 08/16/2024
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Last Update Date | 08/16/2024
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Provider Practice Location Address
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Address Line | 1125 LANCASTER AVE STE 2
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City | BERWYN
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State | PA
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Zip | 19312-2601
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Country | US
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Telephone | 610-557-0252
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Fax | 610-557-0253
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Provider Business Mailing Address
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Address Line | 1125 LANCASTER AVE STE 2
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City | BERWYN
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State | PA
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Zip | 19312-2601
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Country | US
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Telephone | 610-557-0252
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Fax | 610-557-0253
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Authorized Official
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Title or Position | OWNER
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Name | JACQUELINE PALMA WINGATE
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Credential | DMD
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Telephone | 610-557-0252
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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