Provider Demographics
NPI:1033167242
Name:LATOCHA, FABIAN DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:FABIAN
Middle Name:DAVID
Last Name:LATOCHA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13380 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-9474
Mailing Address - Country:US
Mailing Address - Phone:847-746-7517
Mailing Address - Fax:
Practice Address - Street 1:202 S GREENLEAF ST
Practice Address - Street 2:SUITE A
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3399
Practice Address - Country:US
Practice Address - Phone:847-623-2830
Practice Address - Fax:847-623-1534
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery