MEDICARE: WALTER TATCH, D.D.S., LTD.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	021002076	IL

General Provider Information

NPI Number	:	1356423891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALTER TATCH, D.D.S., LTD.

Provider Business Mailing Address
First Line	:	310 S GREENLEAF ST STE 203
Second Line	:
City	:	GURNEE
State	:	IL
Zip	:	60031-5708
Country	:	US
Telephone Number	:	847-623-5915
Fax Number	:	847-623-1174

Provider Business Practice Location Address
First Line	:	310 S GREENLEAF ST STE 203
Second Line	:
City	:	GURNEE
State	:	IL
Zip	:	60031-5708
Country	:	US
Telephone Number	:	847-623-5915
Fax Number	:	847-623-1174

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DR. DIANA MANDEL-TATCH
Credential	:
Telephone Number	:	972-898-5336

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

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