Provider Demographics
NPI:1942382494
Name:MANDEL-TATCH, DIANA (DDS)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MANDEL-TATCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 OSTERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4375
Mailing Address - Country:US
Mailing Address - Phone:847-623-5915
Mailing Address - Fax:
Practice Address - Street 1:700 OSTERMAN AVE
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4375
Practice Address - Country:US
Practice Address - Phone:847-520-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19025855122300000X
IL0190258551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Single Specialty