Provider Demographics
NPI:1245418342
Name:WALTEMATE, THOMAS L (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:WALTEMATE
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:PO BOX 218
Mailing Address - Street 2:403 S CHARLES
Mailing Address - City:STEELEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62288
Mailing Address - Country:US
Mailing Address - Phone:618-965-9213
Mailing Address - Fax:618-965-9213
Practice Address - Street 1:403 S CHARLES
Practice Address - Street 2:
Practice Address - City:STEELEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62288
Practice Address - Country:US
Practice Address - Phone:618-965-9213
Practice Address - Fax:618-965-9213
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A14702122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice