Healthcare Provider Details

I. General information

NPI: 1154578698
Provider Name (Legal Business Name): DR WALTER B BUSSE &ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 E 162ND ST
SOUTH HOLLAND IL
60473-2326
US

IV. Provider business mailing address

536 E 162ND ST
SOUTH HOLLAND IL
60473-2326
US

V. Phone/Fax

Practice location:
  • Phone: 708-331-2322
  • Fax:
Mailing address:
  • Phone: 708-331-2322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019014809
License Number StateIL

VIII. Authorized Official

Name: DR. WALTER BERGE BUSSE
Title or Position: PRESIDENT
Credential: DDS
Phone: 708-331-2322