Healthcare Provider Details

I. General information

NPI: 1285714568
Provider Name (Legal Business Name): DR. WALTER TATCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S GREENLEAF ST STE 203
GURNEE IL
60031-5708
US

IV. Provider business mailing address

700 OSTERMAN AVE
DEERFIELD IL
60015-4375
US

V. Phone/Fax

Practice location:
  • Phone: 847-623-5915
  • Fax: 847-623-1174
Mailing address:
  • Phone: 847-623-5915
  • Fax: 847-623-1174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021002076
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number021002076
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: