Healthcare Provider Details

I. General information

NPI: 1356423891
Provider Name (Legal Business Name): WALTER TATCH, D.D.S., LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/14/2013
Certification Date:
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

310 S GREENLEAF ST STE 203
GURNEE IL
60031-5708
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 TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021002076
License Number StateIL

VIII. Authorized Official

Name: DR. DIANA MANDEL-TATCH
Title or Position: OFFICE MANAGER
Credential:
Phone: 972-898-5336