Provider Demographics
NPI:1528217411
Name:THOMAS L. WALTEMATE, DDS, LTD
Entity Type:Organization
Organization Name:THOMAS L. WALTEMATE, DDS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALTEMATE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:618-965-9213
Mailing Address - Street 1:P.O. BOX 218
Mailing Address - Street 2:
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 1:405 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-A147021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty