Provider Demographics
NPI:1174669634
Name:TACHE, DANIEL E (DMD,FAGD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:E
Last Name:TACHE
Suffix:
Gender:M
Credentials:DMD,FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 N 76TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1137
Mailing Address - Country:US
Mailing Address - Phone:414-476-9400
Mailing Address - Fax:414-774-7794
Practice Address - Street 1:2626 N 76TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-1137
Practice Address - Country:US
Practice Address - Phone:414-476-9400
Practice Address - Fax:414-774-7794
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5089-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33755200Medicaid
WI33755200Medicaid