Provider Demographics
NPI:1093197444
Name:WALKER, TASIA DOMINIQUE (RDH)
Entity Type:Individual
Prefix:
First Name:TASIA
Middle Name:DOMINIQUE
Last Name:WALKER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4219 W 83RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-2238
Mailing Address - Country:US
Mailing Address - Phone:773-715-1356
Mailing Address - Fax:
Practice Address - Street 1:333 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2703
Practice Address - Country:US
Practice Address - Phone:312-738-6170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020015063124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist