Provider Demographics
NPI:1336540863
Name:ELLEN E. TKACH, DDS, P.C.
Entity Type:Organization
Organization Name:ELLEN E. TKACH, DDS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:TKACH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-431-4416
Mailing Address - Street 1:1464 TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-4433
Mailing Address - Country:US
Mailing Address - Phone:847-566-7850
Mailing Address - Fax:847-566-7851
Practice Address - Street 1:1464 TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-4433
Practice Address - Country:US
Practice Address - Phone:847-566-7850
Practice Address - Fax:847-566-7851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-021157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1194998252Medicaid