Provider Demographics
NPI:1255163341
Name:TIED MAIN LINE TONGUE TIE PROFESSIONALS.
Entity type:Organization
Organization Name:TIED MAIN LINE TONGUE TIE PROFESSIONALS.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:PALMA
Authorized Official - Last Name:WINGATE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-557-0252
Mailing Address - Street 1:1125 LANCASTER AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19312-2601
Mailing Address - Country:US
Mailing Address - Phone:610-557-0252
Mailing Address - Fax:610-557-0253
Practice Address - Street 1:1125 LANCASTER AVE STE 2
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:PA
Practice Address - Zip Code:19312-2601
Practice Address - Country:US
Practice Address - Phone:610-557-0252
Practice Address - Fax:610-557-0253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty