MEDICARE: MYOFUNCTIONAL ORTHODONTIST 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1558229054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYOFUNCTIONAL ORTHODONTIST LLC

Provider Business Mailing Address
First Line	:	1266 W MAIN ST STE 1
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-1922
Country	:	US
Telephone Number	:	608-471-8740
Fax Number	:

Provider Business Practice Location Address
First Line	:	1266 W MAIN ST STE 1
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-1922
Country	:	US
Telephone Number	:	608-471-8740
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARK KURCHAK
Credential	:	DDS MS
Telephone Number	:	520-491-0799

Provider Enumeration Date	:	01/13/2026
Last Update Date	:	01/13/2026

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