MEDICARE: UNTETHERED TONGUE TIE CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1386217057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNTETHERED TONGUE TIE CENTER LLC

Provider Business Mailing Address
First Line	:	2524 E WEBSTER PL STE 201
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4257
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2524 E WEBSTER PL STE 201
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4257
Country	:	US
Telephone Number	:	414-441-2418
Fax Number	:

Authorized Official
Title or Position	:	OWNER/SOLE MBR
Name	:	DR. MEGAN GRAHAM
Credential	:
Telephone Number	:	414-441-2418

Provider Enumeration Date	:	07/21/2021
Last Update Date	:	07/21/2021

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